Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services you received from March 23, 2021, through March 26, 2021.

You asked the Plan to waive the copayment for the inpatient hospital services. You say that you were admitted due to an infection, so this should be covered in full.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 $245 copayment per day for days 1 through 8 for inpatient hospital care.

Records show that you were in the hospital for three days. You have been asked to pay a $245 copayment per day for the inpatient hospital services, for a total of $735. This copayment applies regardless of the reason for the admission. 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 inpatient hospital services you received from March 23, 2021, through March 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit for hemodialysis provided January 4, 2021, to January 15, 2021.
You asked the Plan to pay for the home visit for hemodialysis. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says this provider is not Medicare certified.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the home visit for hemodialysis provided January 4, 2021, to January 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office services (CPT code 99214) provided on February 4, 2021, and March 8, 2021.
You asked the Plan to waive the copayment for the office services. You say that these were virtual visits and your benefits state that you have a $0 copayment for virtual visits. The Plan denied your request. The Plan says the claims were processed accordingly with your 2021 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). Per your plan benefits, some Telehealth services including consultation, diagnosis, and treatment by a physician or practitioner, for patients in certain rural areas or other places approved by Medicare. Telehealth services to diagnose, evaluate, or treat symptoms of a stroke. Virtual check-ins (for example, by phone or video chat) with your doctor for 5-10 minutes if: you're not a new patient and the evaluation isn't related to an office visit in the past 7 days and the evaluation doesn't lead to an office visit within 24 hours or the soonest available appointment. Evaluation of video and/or images you send to your doctor, and interpretation and follow-up by your doctor within 24 hours if: you're not a new patient and the evaluation isn't related to an office visit in the past 7 days and the evaluation doesn't lead to an office visit within 24 hours or the soonest available appointment. Consultation your doctor has with other doctors by phone, internet, or electronic health record if you're not a new patient. You will pay the cost-sharing that applies to primary care services or specialist physician services. Therefore, you are asked to pay a $50 copayment per date of service for February 4, 2021, and March 8, 2021. 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 office services (CPT code 99214) provided on February 4, 2021, and March 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for an inpatient admission provided from December 25, 2020, through January 4, 2021.

You asked the Plan to pay for the inpatient admission. You say that you were assured there would be no lapse in coverage over the calendar years. The Plan denied your request. The Plan says inpatient admission began on December 25, 2020 under a different insurance Plan.

The Plan must follow Medicare rules. Medicare rules say that if coverage under a Medicare Advantage (MA) plan begins while the beneficiary is inpatient in a hospital facility, payment for inpatient services until the date of the beneficiary's discharge is made by the previous MA organization, or Original Medicare, as appropriate. 

We looked at the file and Medicare rules. The file shows that you were covered under a different insurance plan when the inpatient admission began. Based on Medicare rules, payment for the inpatient services until the date of discharge is made by the previous MA organization, or Original Medicare as appropriate. Therefore, we decided that the Plan does not have to pay for an inpatient admission provided from December 25, 2020, through January 4, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the requested IRF care is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for IRF care have not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of the enrollee's nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The enrollee does require physical and occupational
therapy but there is no documented need for an intensive rehabilitation program. There is not a reasonable expectation that the enrollee 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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that you prefer to be admitted to acute rehab because you were independent and active before your hospitalization and want to return to being independent. The Plan denied your request. The Plan says the notes do not show a need for close care (face to face visit at least 3 days a week) from a physician specializing in the field or Physical Medicine and Rehabilitation. The Plan states your medical conditions are chronic and stable and your rehabilitation needs are also not complex enough to require coordinated care between therapy disciplines. The Plan states your care needs can be met in the skilled nursing facility setting and the request for admission to acute inpatient rehabilitation is denied as not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for a fall with head trauma and for a urinary tract infection. Medical conditions are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. You do require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that you 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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You are living in a skilled nursing facility after an ankle fracture and burn of the thigh. You have completed treated for cellulitis. Medical conditions are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation
therapy program. You do require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that you 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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on October 9, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the laboratory services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.
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 laboratory services provided on October 9, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (G0483) provided June 30, 2020.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan
denied your request. The Plan says the documentation does not support the services billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT code G0483 is not supported in the medical record. Specifically, the place of service listed on
the claim (81, laboratory) does not match the place of service detailed in the records (11, office setting). Based
on this information, we decided that Medicare rules for coverage of the lab services have not been met.
Therefore, we decided that the Plan does not have to pay for lab services (G0483) provided June 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second opinion to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the OON second opinion. You say that this is an extremely aggressive cancer, and your oncologist has recommended a second opinion before chemotherapy, to be sure on how to proceed. The Plan denied your request. The Plan says there are participating providers who can supply a second opinion.
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 you with second opinion services. We found no exception that would require the Plan to pre-approve OON services. Therefore, we decided that the Plan does not have to pre-approve a second opinion to be provided by an out of network (OON) provider.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Evenity.
You asked the Plan to pre-approve Evenity. You say that you feel it is medically necessary to start the enrollee's treatment with anit-resportive therapy rather than anabolic therapy. The Plan denied your request. The Plan says that the enrollee has not tried and failed the preferred drugs.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. We find that the drug was denied based on step therapy requirements. We requested the documentation that explains this. The documentation was never received. Without the documentation, we cannot confirm that criteria has not been met. Therefore, we decided that the Plan has to pre-approve Evenity.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for a periodic oral evaluation (D0120), bitewing radiographic images (D0274), and a teeth cleaning (D1110) provided on October 20, 2020.
You asked the Plan to pay an additional amount for a periodic oral evaluation, bitewing radiographic images, and a teeth cleaning. You say that you want the Plan to pay an additional amount for the services. The Plan denied your request. The Plan says the claims for these services were processed correctly with the applicable out-of-network allowable amount paid.
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.
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a periodic oral evaluation), bitewing radiographic images, and a teeth cleaning have not been met. Specifically, the allowed amount of these services for an out-of-network provider were paid by the plan. Any amount beyond the allowed amount is your contractual responsibility. Therefore, we decided that the Plan does not have to pay an additional amount for a periodic oral evaluation (D0120), bitewing radiographic images (D0274), and a teeth cleaning (D1110) provided on October 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
You asked the Plan to pre-approve the Freestyle Libre CGM. You say that the requested therapy is clinically appropriate and would benefit the enrollee. The Plan denied your request. The Plan says the criteria for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based
on the blood glucose testing results. The rules also say that information must be furnished by the requestor to
show that the Medicare coverage criteria have been met.
We looked at the file and Medicare rules. The records show that the Plan made reasonable attempts to obtain
medical records. However, no documentation was supplied which indicated that the enrollee uses insulin with
at least three daily injections. Based on this information, we decided that Medicare rules for coverage of the
Freestyle Libre CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a
Freestyle Libre continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the total electric hospital bed (E0265) provided December
25, 2020.

You asked the Plan to pay for the total electric hospital bed. You say that you believe this is incorrectly
denying because you had coverage of a hospital bed. The Plan denied your request. The Plan says a total
electric hospital bed is never covered by Medicare.

The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.

While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers
coverage for this item. Of note, the original approval was for a semi-electric hospital bed. While the enrollee
was approved for this item, it appears this was upgraded to a total electric hospital bed which is never covered.
Therefore, we decided that the Plan does not have to pay for the total electric hospital bed (E0265) provided
December 25, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on April 13, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service
(POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting.
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on April 13,
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for therapy services (97110) provided July 7, 2020.

You asked the Plan to pay for the therapy services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed services.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

We find that CPT code 97110 is not supported in the medical record. Specifically, the record shows the services were provided in the home setting. There is a more appropriate CPT code to describe these services in this setting (G0158). Based on this information, we decided that Medicare rules for coverage of the therapy services have not been met. Therefore, we decided that the Plan does not have to pay for therapy services (97110) provided July 7, 2020.