Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH)
for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan
denied your request. The Plan says care can be provided in the current inpatient hospital.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in
general, LTACHs do not provide clinical services that are materially different than those of short-term acute
care hospitals. In this case, ongoing care needs include oxygen supplementation, surveillance laboratory
studies, electrolyte repletion, fluid balance, oral antibiotics, and therapy services. The documentation does not
support that the enrollee in this case requires services at the LTACH that are not available at the acute care
hospital where he is currently receiving care. There are no required medical services identified that are
available at the LTACH, that are not available at the current health care setting being offered by the health
plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate
for the diagnosis and condition of the enrollee at this time.
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. 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 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 acute care hospital (ACH) for respiratory failure related to CoViD-19 and pneumonia. The enrollee was intubated/ventilated and subsequently received a tracheotomy. The enrollee remains ill and in need of active therapies. There is no evidence that the enrollee requires services that are not currently available. 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 (LTC) 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 long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement for the wig (A9282).
You asked the Plan to issue reimbursement for the wig. You say that you are requesting a reconsideration of the Plan's denial for payment of the wig purchased as it is medically necessary. The Plan denied your request. The Plan says this item is not a covered benefit under your contractual policy for your condition.
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are ordered by a physician. The Plan follows these same rules. In this case, although the wig may be appropriate, it does not meet the definition of the above benefit criteria.
It is not considered DME because it does not directly treat a medical condition. It does not meet the Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would provide coverage for a wig for your condition. The Plan contract indicates that wigs are only covered when you experience hair loss that is a result of Chemotherapy. Therefore, we decided that the Plan does not have to issue reimbursement for the wig (A9282).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe office visits provided from August 1, 2019 through August 30, 2019.You asked the Plan to waive the copayment forthe office visits. You say that the provider doesn't accept insurance payments. You say that you should be reimbursed.The Plan denied your request. The Plan says the copayments 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 $40 copayment for outpatient substance abuse services at an in-network specialist's office.You have been asked to pay $14, which is less than the standard $40 copayment for each office visit. The total amount you owe is $434 ($14/visit x 31 visits = $434). The office visits fall within the "Outpatient substance abuse 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 office visits provided from August 1, 2019 through August 30, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on December 1, 2019.
You asked the Plan to waive the copayment for the ambulance transport. You say that insurance should pay for the ambulance as in-network. You say that you are not responsible. 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 $265 copayment per date of service regardless of the number of trips for ground ambulance. You have been asked to pay a $265 copayment for the ambulance transport. The ambulance transport falls within the "Ambulance 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 for the ambulance transport provided on December 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cardiology services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the OON services. You say that the enrollee's quality of life can decline with his history of coronary artery disease and aortic stenosis. The Plan denied your request. The Plan says there are in-network providers that are available to meet the enrollee's care needs.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve cardiology services to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a walk-in shower/tub (E1399).
You asked the Plan to pre-approve a walk-in shower/tub. You say that this is medically necessary for you due to your age and medical issues. A tub chair or handrail would not be sufficient. The Plan denied your request. The Plan says this is considered a convenience item and is not covered.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a walk-in shower/tub (E1399).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health services provided on February 5, 2020 by an out of network(OON) provider.You asked the Plan to pay for outpatient mental health services. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says there are three in-network providers available within a reasonable distance. The Plan says that no prior authorization was 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 outpatient mental health services provided on February 5, 2020 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional mileage for routine transportation trips.
You asked the Plan to pre-approve additional mileage for routine transportation trips. You say that the additional mileage is needed. The Plan denied your request. The Plan says the requested additional mileage exceeds the benefit limit. Therefore, coverage criteria has not been met.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers 36 one-way transportation trips per calendar year when each one-way trip does not exceed 50 miles. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve additional mileage for routine transportation trips.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided on October 2, 2019.You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that you disagree with the charges beyond the copayment.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 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay $245.14, which is less than the 20% coinsurance for Medicare Part B drugs. Medicare Part B drugs fall within the Medicare Part B prescription drugs 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 coinsurance for Medicare Part B drugs provided on October 2, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe assistant surgeon services rendered on October 29, 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 the services are not covered.The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for CPT codes 19330, 11970, and 15777. The Medicare Fee Schedule Database contains a surgical indicator of 1 for these procedures. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for these services have not been met. Therefore, we decided that the Plan does not have to pay forthe assistant surgeon services rendered on October 29, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 2D oral/facial photographic image, problem focused
limited oral evaluation, crown, prefabricated post and core in addition to crown, and endodontic therapy.
You asked the Plan to pay for the 2D oral/facial photographic image, problem focused limited oral evaluation,
crown, prefabricated post and core, and endodontic therapy. You say that you contacted the Plan prior to
having the services rendered and were referred to this provider. You also say that you were informed that you
were covered. The Plan denied your request. The Plan says these services are not covered benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 2D
oral/facial photographic image, problem focused limited oral evaluation, crown, prefabricated post and core in
addition to crown, and endodontic therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician services and treatment to be provided by an
out of network (OON) provider.
You asked the Plan to pre-approve physician services and treatment. You say that this is the only clinic that can
provided this specific treatment. The Plan denied your request. The Plan says there are in-network providers
capable of providing 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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
physician services and treatment to be provided by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the hyaluronan injection
You asked the Plan to waive the coinsurance for the hyaluronan injection. You say that you were not informed
there would be coinsurance for the service. You say that if you were informed in advance you could have
decided if you wanted the service. The Plan denied your request. The Plan says the coinsurance 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 20%
coinsurance for preferred Medicare Part B covered drugs from an in-network provider.
You have been asked to pay$132.82, which is 20% of the allowed amount for the hyaluronan injection. The
allowed amount is $664.08 (20% x $664.08 = $132.82). The hyaluronan injection falls within the "Medicare
Part B prescription drugs" 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 coinsurance for the
hyaluronan injection
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99205) and drug test (80307 and G0483).
You asked the Plan to pay for the office visit and drug test. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says it is the provider's responsibility to bill the Health Plan or any liability insurance before submitting the claim to the Plan.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible for the office visit and drug test until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for an office visit (99205) and drug test (80307 and G0483).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (CPT 85060) provided to the enrollee on July 10, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says this is an inappropriate place of service for a physician interpretation.
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 85060 is "Blood smear, peripheral, interpretation by physician with written report." We find that CPT code 85060 is not supported in the medical record. Specifically, this code may not be paid if furnished to hospital outpatients or non-hospital patients. The enrollee received outpatient services. 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 pay for lab services (CPT 85060) provided to the enrollee on July 10, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bilateral brachioplasty.
You asked the Plan to pre-approve a bilateral brachioplasty. You say that you would like reconsideration because this service will significantly reduce the member's injury risk and will facilitate activities of daily living. The Plan denied your request. The Plan says this service is cosmetic in nature.
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 a bilateral brachioplasty. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the member does not have evidence of functional impairment due to his soft tissue excess that has failed reasonable conservative management. The member is not noted to have chronic dermal irritation that has failed typical dermatologic management. There has not been sufficient documentation of typical functional abnormalities related to his skin excess that has failed conservative 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 a bilateral brachioplasty have not been met. Therefore, we decided that the Plan does not have to pre-approve a bilateral brachioplasty.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF admission. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed 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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee spends most time in bed. The enrollee does not have complex wound care, a need for IV fluids, or require enteral feedings. The documentation does not support that the enrollee requires the specialized skills, knowledge, or judgment of a skilled professional nurse or qualified therapist to safely and effectively provide medically necessary and reasonable treatment. The documentation does not support that skilled nursing or skilled therapy services are required on a daily basis. As a practical matter, the enrollee does not require the necessary services on an inpatient basis, at a SNF level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).