Persius/hicric huggingface dataset:
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 intensive therapy is needed to allow the enrollee to progress. The Plan denied your request. The Plan says there are no acute medical conditions, and the enrollee cannot tolerate three hours per day of therapy.
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 complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for a lower extremity vascular bypass procedure in November 2020 and has been discharged home where they are receiving home health services. There is ongoing weakness. Medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that this patient 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this transfer is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not 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 there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. He does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 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 for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approveproton beam therapy.You asked the Plan to pre-approveproton beam therapy. You say that this patient has high risk prostate cancer and needs to start this therapy immediately.The Plan denied your request. The Plan says proton beam therapy is not the standard of care for this patient's condition.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 proton beam therapy. Our reviewer says that proton beam therapy is not considered medically reasonable and necessary in this case. Our physician reviewer found while proton beam is not an experimental therapy, any potential benefit or detriment of proton therapy over standard intensity modulated radiation therapy (IMRT) is an investigational question that is being pursued in randomized studies. Other treatment approaches are also highly effective and well tolerated.To date, there are no compelling data to suggest that proton therapy is superior to or more beneficial than IMRT. The generally accepted standard of care for prostate cancer is to only offer proton beam therapy on clinical trials, and to not routinely offer it to patients. Both ASTRO and the NCCN guidelines recommend against routine use of proton therapy.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of proton beam therapy have not been met.Therefore, we decided that the Plan does not have to pre-approveproton beam therapy.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe diagnostic mammography provided on June 18, 2020.You asked the Plan to waive the copayment forthe diagnostic mammography. You say that you never had to pay a copayment before.The Plan denied your request. The Plan says you were charged the copayment 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 $150 copayment for outpatient diagnostic tests. You have been asked to pay a $150 copayment for the diagnostic mammography. The diagnostic mammography falls 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 copayment forthe diagnostic mammography provided on June 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe limited oral evaluation (D0140) provided on August 12, 2020.You asked the Plan to pay forthe dental service. You say that you were traveling to Georgia. You say that while you were out of town, you needed dental services. You say that they were necessary due to an abscess.The Plan denied your request. The Plan says 1 limited oral evaluation per plan year is covered. The Plan says that the frequency limit for this service has been exceeded.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 frequency limit of 1 limited oral evaluation per plan year has been exceeded. The record shows that the Plan paid for this service that you received on May 20, 2020.Therefore, we decided that the Plan does not have to pay forthe limited oral evaluation(D0140) provided on August 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on July 16, 2020, by an OON provider.You asked the Plan to pay fornursing facility care. You say that due to COVID-19 authorizations are waived.The Plan denied your request. The Plan says these out of network services were provided 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 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 medical services provided on July 16, 2020, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe porcelain/ceramic crown (D2740) provided on August 17, 2020.You asked the Plan to pay forthe porcelain/ceramic crown. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says this service exceeds the frequency limitation.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. The Plan covers the porcelain/ceramic crown once per tooth every five years. We looked at the file and Medicare rules. The file indicates that you last had this service provided in 2017 which means you had exhausted your benefit until 2022. Based on this information, we decided that the Plan's rules for coverage of the porcelain/ceramic crown have not been met.Therefore, we decided that the Plan does not have to pay forthe porcelain/ceramic crown (D2740) provided on August 17, 2020
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that it is felt LTACH is needed to make room for other patients and to meet the enrollee's needs due to limited capacity.The Plan denied your request. The Plan says LTACH care is not medically necessary.The Plan must followMedicare 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 patient is a 77-year-old male who was admitted to the current acute care hospital with COVID-19 pneumonia and was treated with steroids, antibiotics, remdesivir, convalescent plasma, oxygen, and anticoagulation for a PE. He currently still requires high flow oxygen but is stable.The patient appears to be stable and is gradually improving but requires additional short-term acute care services for oxygen weaning which can safely be performed at the current facility. The patient does not require anyservices at the LTACH that are not already available at the current facility. Therefore, this request for LTACH services will be considered not medically necessary. Ongoing treatment at the current facility is appropriate until the patient is able to be transferred to 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 the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on June 22, 2020, by an OON provider.You asked the Plan to pay fornursing facility care. You say that due to COVID-19 authorizations are waived.The Plan denied your request. The Plan says these out of network services were provided 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 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 medical services provided on June 22, 2020, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on February 10, 2020 by a non-network provider.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services were rendered by a non-network 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 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 medical services provided on February 10, 2020 by a non-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forlimited oral evaluation -problem focused (D0140), endodontic therapy, molar tooth (excluding final restoration) (D3330), endodontic therapy, premolar tooth (excluding final restoration) (D3320), and intraoral -periapical first radiographic image (D0220) provided on January 14, 2020, and January 27, 2020.You asked the Plan to pay forlimited oral evaluation, endodontic therapies, intraoral -periapical first radiographic image. You say that the services should be covered.The Plan denied your request. The Plan says services done by an out-of-network provider are not covered.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. Services must be provided by a participating provider in order to be covered.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. Specifically, you received services from a non-participating provider.Therefore, we decided that the Plan does not have to pay forlimited oral evaluation -problem focused (D0140), endodontic therapy, molar tooth (excluding final restoration) (D3330), endodontic therapy, premolar tooth (excluding final restoration) (D3320), and intraoral -periapical first radiographic image (D0220) provided on January 14, 2020, and January 27, 2020
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ER visit provided on July 30, 2020.You asked the Plan to waive the copayment forthe ER visit. You say that the hospital didn't have you void prior to releasing you. You say that you shouldn't have to pay any copayments associated to the surgery.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 $90 copayment per visit for Medicare-covered emergency care.You have been asked to pay a $90 copayment for the ER visit. The ER visit falls within the "Emergency care" benefit category. The records show that you were treated in the ER. 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 ER visit provided on July 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe telehealth specialist physician service provided on September 30, 2020.You asked the Plan to waive the copayment forthe telehealth specialist physician service. You say that [Enter appellant's argument from appeal letter, e.g. "...you need SNF care."]The Plan denied your request. The Plan says you were charged this copayment 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 $45 copayment for physician services. You have been asked to pay a $45 copayment for the telehealth specialist physician service. the telehealth specialist physician service falls within the 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 copayment forthe telehealth specialist physician service provided on September 30, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forselective catheter placement, arterial system; thoracic or brachiocephalic branch (36217) provided November 6, 2019.You asked the Plan to pay forthe surgical procedure. You say that attached are the medical records as requested.The Plan denied your request. The Plan says this service is not supported in the medical records. This description was not documented in the operate report narrative.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 36217 is initial third order or more selective thoracic or brachiocephalic branch, within a vascular family.We find that CPT code 36217 is not supported in the medical record. Specifically, the operative report did not include documentation of a selective catheter placement into the arterial system, for the initial third order or more selective thoracic or brachiocephalic branch, within a vascular family.Based on this information, we decided that Medicare rules for coverage of the surgical procedure have not been met.Therefore, we decided that the Plan does not have to pay forselective catheter placement, arterial system; thoracic or brachiocephalic branch (36217) provided November 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora knee orthosis (L1833) provided to the enrollee on March 17, 2020.You asked the Plan to pay forthe orthosis. You say that the claim should be paid.The Plandenied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.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 does not contain a valid proof of delivery which support medical necessity for the supplies provided in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success.Therefore, we decided that the Plan does not have to pay fora knee orthosis (L1833) provided to the enrollee on March 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forhearing aid services (V5010) provided on July 16, 2020.You asked the Plan to pay forhearing aid services. You say that since the provider you saw is in-network with the Plan, you believe that the services should be eligible for payment.The Plan denied your request. The Plan says you must see the Plan's hearing aid vendor for these services to be covered.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 the services are received from the Plan's hearing aid vendor. We looked at the file and the Plan's rules. Although you received the services from a contracted provider with the Plan, the provider was not contracted with the Plan's hearing aid vendor. Based on this information, we decided that the Plan's rules for coverage of hearing aid services have not been met.Therefore, we decided that the Plan does not have to pay forhearing aid services (V5010) provided on July 16, 2020.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to reduce the copayments for nursing facility care. We decided that the Plan does not have to waive the copayments for the nursing facility care.
You asked the Plan to waive the copayments for nursing facility care. You say that all the claims were covered until April 2019 now you are getting billed for over $800. The Plan says the $40 copayments applied correctly.
We decided that the Plan has to reduce the copayments for nursing facility care.
The Plan contract clearly says that you must pay a $5 copayment for a PCP office visit. The provider is listed as a family nurse practitioner, which is considered a primary care physician. Therefore, we decided that the Plan has to reduce the $40 copayments to $5 copayments for the nursing facility care visits.
We also decided that the Plan does not have to waive the copayments for the nursing facility care.
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 a PCP office visit/ other health care professional. Therefore, we decided that the Plan does not have to waive the copayments for the nursing facility care.
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.