Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Partially Favorable

We decided that the Plan has to pre-approve a tendon repair. We decided that the Plan does not have to preapprove
a partial claviculectomy.
You asked the Plan to pre-approve a partial claviculectomy and a tendon repair. You say that the requested
services are a medical necessity for the enrollee. The Plan says that rules for coverage have not been met
because the requested services are not medically necessary.
We decided that the Plan has to pre-approve a tendon repair.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item
or service, then that item or service will be covered when it is medically 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 a tendon repair. Our reviewer says that a tendon repair is medically reasonable and necessary. Our physician reviewer found that the full thickness tear of the rotator cuff would not be expected to heal with any further conservative measures or time. Trial and failure of conservative treatment modalities has been documented. 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 tendon repair have been met. Therefore, we decided that the Plan has to pre-approve a tendon repair.
We also decided that the Plan does not have to pre-approve a partial claviculectomy.
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 partial claviculectomy. Our reviewer says that a right shoulder partial claviculectomy is not medically reasonable. Our physician reviewer found that clinical and arthrogram findings (along with the prior distal clavicle resection and medical literature) does not support (another) partial clavicle resection in this setting of rotator cuff tear/repair. 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 partial claviculectomy have not been met. Therefore, we decided that the Plan does not have to pre-approve a partial claviculectomy.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a transthoracic echocardiogram (93306) provided on March 10, 2021.
You asked the Plan to pay for a transthoracic echocardiogram. You say that this is supported in the records. The Plan denied your request. The Plan says this was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that when billing transthoracic echocardiography as a pre-operative service, a secondary diagnosis for mitral valve prolapse is also required. We looked at the file and Medicare rules. The record shows that the service at issue was performed pre-operatively, but it was not billed with a secondary diagnosis.
Based on this information, we decided that Medicare rules for coverage of a transthoracic echocardiogram have not been met. Therefore, we decided that the Plan does not have to pay for a transthoracic echocardiogram (93306) provided on March 10, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient rehabilitation stay provided
from October 6, 2020, to October 15, 2020.
You asked the Plan to waive the copayment for an inpatient rehabilitation stay. You say that you disagree with
how the claim was processed and this should be considered a continuation of acute care with no additional
copayment. The Plan denied your request. The Plan says the claims were processed correctly, and the enrollee
is 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). The enrollee's contract with the Plan clearly says that enrollees
must pay a $390 copayment for days 1-5 for inpatient hospital care. The inpatient cost share will begin on day
one each time enrollees are admitted or transferred to a specific facility type, or inpatient rehabilitation
facilities.
The enrollee had an inpatient rehabilitation stay from October 6, 2020, to October 15, 2020. This is considered
a new inpatient hospital admission. Therefore, the enrollee is responsible to pay a $390 copayment for days 1-5
(October 6, 2020, to October 10, 2020). $390 (copayment) x 5 (inpatient days) = $1,950.
The enrollee has been asked to pay a $390 copayment for an inpatient rehabilitation stay. An inpatient
rehabilitation stay falls within the inpatient hospital care benefit category. This means that the enrollee has been
asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not
have to waive the copayment for an inpatient rehabilitation stay provided from October 6, 2020, to October 15,
2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve the SNF admission. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary or reasonable.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 the SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require daily skilled nursing or skilled therapy services. 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 SNF admission have not been met. Specifically, medically necessary services can be provided at a lower level of care. This means admission to a SNF is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) admission.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on September 15, 2020 by an OON provider.
You asked the Plan to pay for the subsequent nursing facility care. You say that the treating provider was unaware that the enrollee's nursing facility did not request a prior authorization for this date of service. The Plan denied your request. The Plan says the services were rendered by a non-participating provider. The Plan also says that prior authorization was not obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care provided on September 15, 2020 by an OON provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a walk-in shower.
You asked the Plan to pre-approve the shower. You say that you cannot get into the bathtub currently. The Plan denied your request. The Plan says appropriate documentation to support the medical necessity of the request was not submitted.
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.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on February 22, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not approved in advance.
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 had network providers available who could have provided 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 services provided by an out-of-network provider on February 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the nuclear myocardial perfusion study you had at an outpatient hospital facility on March 31, 2021.
You asked the Plan to waive the copayment for the nuclear myocardial perfusion study. You say that you were told there would be no cost for this test. 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 $300 copayment for advanced imaging and nuclear medicine services. You have been asked to pay a $300 copayment for the nuclear myocardial perfusion study. The nuclear myocardial perfusion study falls within the advanced imaging and nuclear medicine 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 nuclear myocardial perfusion study you had at an
outpatient hospital facility on March 31, 2021.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the service is medically necessary. The Plan denied your request. The Plan says that the services are not medically necessary or reasonable.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the service is medically necessary. Our physician reviewer found the enrollee has skilled therapy needs that require daily skilled services to establish a maintenance program for the enrollee's condition. The enrollee appears to be suffering an abrupt decline in function. A trial of skilled therapy is reasonable to see if improvements in function can be achieved. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have been met. Specifically, the enrollee's care cannot be provided at a lower level of care. This means admission into a SNF is medically necessary. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing facility (SNF) 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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit (99213) provided on April 2, 2021.
You asked the Plan to waive the copayment for a specialist office visit. You say that this should be fully covered. The Plan denied your request. The Plan says this processed 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 each specialist office visit. You have been asked to pay a $45 copayment for a specialist office 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 a specialist office visit (99213) provided on April 2, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eight (8) additional PT visits.
You asked the Plan to pre-approve eight (8) additional PT visits. You say that additional PT is medically necessary. The Plan denied your request. The Plan says additional PT is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 eight (8) additional PT visits. Our
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the additional requested therapy is not generally accepted as specific and effective therapy for your condition beyond what was approved by the health Plan. You have had prior extensive therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. You have been instructed in a home exercise program. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of eight (8) additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve eight (8) additional PT visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206) provided on January 4, 2021.
You asked the Plan to pay for the topical application of fluoride varnish. You say that you believe you were billed incorrectly for the topical application of fluoride varnish. The Plan denied your request. The Plan says this service is 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. 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 topical application of fluoride varnish (D1206) provided on January 4, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the home ventilator and supplies provided on January 29, 2021 and February 28, 2021 by an out of network provider.
You asked the Plan to pay for the home ventilator and supplies (E0466, A7030, A7035, A7037 A7038, A7039). You say that the Plan should pay this claim. The Plan denied your request. The Plan says you did not request prior authorization for the out-of-network services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items at issue in this appeal. The Plan did not pre-approve the items at issue. We found no exception that would require the Plan to pay for these items. Therefore, we decided that the Plan does not have to pay for the home ventilator and supplies provided on January 29, 2021 and February 28, 2021 by an out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional tooth to existing partial denture (D5650) provided March 8, 2021.
You asked the Plan to pay for the additional tooth to existing partial denture. You say that you were not aware the service is not covered under your benefits. The Plan denied your request. The Plan says this service is not covered under your dental 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 additional tooth to existing partial denture (D5650) provided March 8, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting on January 1, 2021.
You asked the Plan to pay for the self-administered drugs. You say that you were in the hospital with a stroke. You say that you feel that it should have been paid by your medical insurance.
The Plan denied your request. The Plan says the drugs you received are considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the drugs you received are not covered under Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting on January 1, 2021.
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit provided by an out-of-network provider on September 11, 2020.
You asked the Plan to pay for the home visit. You say that authorization was impossible with incorrect insurance information. You say that patient required the medical care received from the provider and the claim should be reprocessed for payment. The Plan denied your request. The Plan says members must receive care from an in-network provider.
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 had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the home visit provided by an out-of-network provider on September 11, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for non-emergent ambulance transport provided to the enrollee on February 8, 2021.
You asked the Plan to pay for this transport. You say that this transport was medically necessary. The Plan denied your request. The Plan says based on the records provided, the enrollees condition would not have been endangered by other means of transportation.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. The medical records show the enrollee was taken to the hospital for ongoing treatment for cancer. This was not an emergent transport. Based on this information, we decided that Medicare rules for coverage of this transport have not been met. Therefore, we decided that the Plan does not have to pay for non-emergent ambulance transport provided to the enrollee on February 8, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on November 16, 2020.
You asked the Plan to pay for lab tests. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the documentation submitted does not support the Place of Service (POS) code billed on this claim.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for service, the place where the sample was taken is reported as the Place of Service (POS). We looked at the file and Medicare rules. The documentation submitted shows that the sample for this testing was taken in an office setting. Therefore, the POS code 81 - indicating an independent lab setting - is not appropriate for this claim. Based on this information, we decided that Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on November 16, 2020.