Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on August 22, 2019.
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied 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. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on August 22, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy to be provided by the out of network provider.
You asked the Plan to pre-approve physical therapy. You say that you filed a complaint for the in-network approved provider. The Plan denied your request. The Plan says there are in-network providers available.
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 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. 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 physical therapy to be provided by the out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve expandable controller (E2377) expandable controller harness (E2313) and electronic connector to 2 power options (E2311).
You asked the Plan to pre-approve the power wheelchair accessories. You say that you are not asking for anything that is not medically necessary based on the enrollee's medical condition. The Plan denied your request. The Plan says the upgraded electronics are not medically necessary.
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 power wheelchair accessories. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not reveal that the enrollee requires a proportional input device, an attendant control, other electronic devices such as augmentative speech device, a separate display, a non-proportional input device such as sip and puff, or the need to control 3 or more power seating actuators through the drive control. The enrollee's strength and ability to feed himself independently reveal his function is sufficient to control the power options with their separate switches already included with the approval of these power options. 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 power wheelchair accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve expandable controller (E2377) expandable controller harness (E2313) and electronic connector to 2 power options (E2311)
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee is medically stable, with no clinical evidence of any unstable medical or rehab conditions requiring this level of 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 there are no identifiable skilled nursing service needs. 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on August 20, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 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 physician's services provided on August 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an occipital nerve block injection and trigger point injection.
You asked the Plan to pre-approve the injections. You say that this is medically necessary. The Plan denied your request. The Plan says these services are considered experimental and investigational.
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 injections. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the treatment of occipital neuralgia and other types of headaches is considered experimental and investigational. Trigger point injections for the management of headaches are also considered experimental. Additionally, in this case, there is no adequate documentation in terms of degree and duration of pain relief from any of the procedures performed. The requested injections are not considered medically reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the injections have not been met. Therefore, we decided that the Plan does not have to pre-approve an occipital nerve block injection and trigger point injection.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the echocardiogram provided on August 9, 2019.
You asked the Plan to waive the copayment for the echocardiogram. You say that you should not be responsible for the copayment because the nurse practitioner said you needed the service. You say you did not ask for this service and you cannot afford it. 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 $100 copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a physician's office or at a free-standing facility. You have been asked to pay a $100 copayment for the echocardiogram. The echocardiogram falls 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 echocardiogram provided on August 9, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ED visit provided on September 6, 2019.
You asked the Plan to waive the copayment for the ED visit. You say that you had no emergency room service other than the nurse who took your blood pressure. You say that there should be no bill because you did not receive any services. 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 for each emergency room visit. You have been asked to pay a $90 copayment for the ED visit. The ED visit falls within the "Emergency care" benefit category. The records show that you consulted with a doctor and received an injection during the ED visit. 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 ED visit provided on September 6, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the laboratory work provided on October 16, 2019.
You asked the Plan to waive the deductible for the laboratory work. You say that the laboratory work was a part of your yearly physical. You say you have never paid for physical-related things and feel this should be covered. 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. Your contract with the Plan says that there is a $250 deductible that applies towards in-network laboratory services. The laboratory services you asked the Plan to waive the deductible for falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $250 deductible that applies towards in-network laboratory services. The record shows the total allowed amount for the laboratory work is $71.23. Therefore, $71.23 was applied to your $250 deductible.
This cost sharing is a contractual obligation that had not been met at the time the laboratory work was received on October 16, 2019. Therefore, we decided that the Plan does not have to waive the deductible for the laboratory work provided on October 16, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar/sacral facet joint radiofrequency neurolysis.
You asked the Plan to pre-approve the injection. You say that this is medically necessary for your pain. The Plan denied your request. The Plan says the doctor must send notes that show that the pain is from arthritis, and not from a different problem.
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 injection. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found under the coverage criteria provided a repeat denervation procedure requires a greater than or equal to 50% improvement and pain and activities of daily living for at least 6 months. In this case, the last radiofrequency ablation was done in August 2019 and a repeat procedure is being requested less than 6 months afterwards. He has pain rated at 6/10 and a 50% improvement in pain would require a score of no more than 5/10. For these reasons he does not meet criteria for the procedure being requested.
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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar/sacral facet joint radiofrequency neurolysis.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nurse practitioner services provided on September 30, 2019.
You asked the Plan to pay for the nurse practitioner services. The Plan denied your request. The Plan says there is no valid referral for this service.
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 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 nurse practitioner services provided on September 30, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Percepta Bronchial Genomic Classifier test.
You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your request. The Plan says the records do not show a smoking history.
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 testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the case file contains no clinical documentation regarding the enrollee's smoking history, bronchoscopy report, or a plan for monitoring and clinical management. 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 testing have not been met. Therefore, we decided that the Plan does not have to pre-approve the Percepta Bronchial Genomic Classifier test.
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 the enrollee is on epidural for pain control, and requires telemonitoring, and continuous oximetry monitoring. The Plan denied your request. The Plan says the enrollee can be appropriately managed at a SNF level of care.
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 is currently undergoing treatment at an ACH following surgery for colon cancer. The enrollee is not intubated/ventilated. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs. 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient diagnostic testing provided on August 22, 2019.
You asked the Plan to waive the copayment for outpatient diagnostic testing. You say that this should be
covered as preventative services. The Plan denied your request. The Plan says the correct copayment has been
applied.
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 an $85
copayment for outpatient diagnostic services/in-network/diagnostic procedure or test.
You have been asked to pay less than your $85 copayment for outpatient diagnostic testing. The total amount
you are being asked to pay is $91.45 ($36.62 + $54.83 = $91.45). These services are not considered
preventative; therefore, the correct copayments have been applied. Outpatient diagnostic testing falls within the
outpatient diagnostic services/in-network/diagnostic procedure or test. 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 diagnostic testing provided on
August 22, 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 care in the IRF setting would be beneficial. The Plan denied your request. The Plan says there is no need for this level of care. Three hours of daily therapy are not needed nor likely to be completed.
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 was previously on hospice but was taken off and brought to the hospital with shortness of breath. Imaging revealed a left pleural effusion. The member was managed with medical care and oxygen, and improved. Now, there are no signs of hemodynamic instability. The member is afebrile. Creatinine is less than 1.0. Co-morbid conditions include spastic hereditary paraplegia. Significant assist is needed for hygiene and lower body ADL's, and assist is needed for all transfers. Records do not indicate that there are significant, or complex medical/nursing issues that require frequent physician management. Ongoing pain medication and other medication management, O2 care, and daily therapy can be provided at a SNF. In this case, the member is requiring assist for functional transfers and ADL's and a less intensive, longer duration of therapy will allow for measurable gains to be attained within a reasonable and predicted period. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CPAP device (CPT Code E0601), for the enrollee.
You asked the Plan to pre-approve the CPAP device. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says the durable medical equipment is not medically necessary.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the CPAP device have not been met. The additional documentation received does not have updated information related to the compliance of utilization. The previous notes reveal only 2.2% utilization. Therefore, we decided that the Plan does not have to pre-approve CPAP device (CPT Code E0601), for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for SNF care provided from January 10, 2019 through February 7, 2019.
You asked the Plan to waive the copayment for SNF care. You say that you were in pain four (4) days later after being discharged. You state you called 911 and were taken to a hospital where you were diagnosed with a sciatica nerve infection. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received SNF care provided by from January 10, 2019 through February 7, 2019. There were no copayment charges for the first 20 days of SNF care. You are asked to pay a $50 copayment per day after the 21st day of SNF care. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for SNF care provided from January 10, 2019 through February 7, 2019.