Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services.
You asked the Plan to pre-approve SNF services. You say that you are hurting, and need assistance until you get better. The Plan denied your request. The Plan says you do not require complex daily nursing and rehab therapy services.
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 services. Our physician reviewer found that from a nursing perspective, you have stable vital signs, and were treated for pain with effect. There are no identifiable skilled nursing service needs. Regarding rehab services, you are at supervision to minimal assist with functional mobility, and require varying assist with activities of daily living. Although there are identifiable skilled therapy service needs, you do not require skilled nursing or therapy services on a daily basis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urgent care visit provided on October 31, 2018.
You asked the Plan to waive the copayment for the urgent care visit. You say that you could not go to your primary care physician within a reasonable time. You say that you should be refunded. 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 $40 for each Medicare-covered urgently needed service visit. Covered services include a non-emergency, unforeseen medical illness, injury, or condition that requires immediate medical care. You have been asked to pay a $40 copayment for the urgent care visit. The urgent care visit falls within the "Urgently needed services" benefit category. The records show that you were treated during the urgent care 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 urgent care visit provided on October 31, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular nerve ablation.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is still being studied in clinical trials for efficacy.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is an experimental/investigational procedure that is the subject of on-going clinical trials. Therefore, the request is deemed not medically reasonable and 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve genicular nerve ablation.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the specialist office visit provided on August 6, 2019.
You asked the Plan to reduce the copayment for the specialist office visit. You say that you say you went to the same orthopedic doctor on June 18, 2019 and only paid a $10 copayment. You say that all exams moving forward should be charged the $10 amount. 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 $35 copayment per visit for Medicare-covered specialty care services. You have been asked to pay a $35 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows the provider is an orthopedic doctor.
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 reduce the copayment for the specialist office visit provided on August 6, 2019.
Our decision is only about the August 6, 2019 services. If you have any questions about prior billing, please contact the plan directly.
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 the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.
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 admission to an IRF does not meet criteria. Our physician reviewer found the enrollee was admitted to acute care on 1/22/20 with a stroke with left hemiparesis, aphasia, and dysphagia. Her current level of function is sit to stand with minimal assist, supine to sit with minimal assist, ambulating 10 feet with hand held assist with minimal assist x 2, grooming with minimal assist, toileting with minimal assist, and bathing and dressing with moderate assist. Based on available records, the enrollee does not meet criteria for coverage of IRF. The enrollee is currently medically stable and there is no evidence of complex medical issues that require monitoring by an inpatient physician three times per week or acute rehab nursing care. While she may benefit from continuing speech therapy, physical therapy and occupational therapy, there is no evidence of need for an intensive therapy program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation 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 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on August 22, 2019.
You asked the Plan to waive the copayment for the office visit. You say that this was your annual wellness visit. You say that there should be no copayment. 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 $5 copayment per primary care physician (PCP) visit. You have been asked to pay a $5 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show that you were treated for hyperlipidemia and diabetes during the 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 the office visit provided on August 22, 2019.
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 requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not medically necessary.
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 admission to a LTACH is not medically necessary. Our physician reviewer found based on the documentation provided, the enrollee is currently undergoing treatment at an acute care hospital (ACH) for a right lower extremity infection with sepsis. The enrollee was intubated/ventilated upon admission. He initially received a guillotine amputation, which was followed by a below knee amputation. He subsequently received a tracheotomy and has since been weaned from the ventilator. 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 long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to hold you harmless for acupuncture services provided on March 19, 2019 through June 14, 2019.
You asked the Plan to hold you harmless for the acupuncture services. You say that you were told by the Plan that acupuncture services are a covered benefit. The Plan denied your request. The Plan says that Medicare guidelines do not provide coverage for therapy services provided by acupuncturists.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules. You were referred for the acupuncture services. The service provider is a contract provider. The file does not show that the plan provided notice that the acupuncture services would not be covered. Under Medicare rules, this means the acupuncture services is considered approved by the plan. Therefore, we decided that the Plan has to hold you harmless for acupuncture services provided on March 19, 2019 through June 14, 2019.
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: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the emergency room visits provided on August 5, 2019.
You asked the Plan to waive the copayments for the emergency room visits. You say that you should not be responsible for the two emergency room copayments because you do not want to pay twice for the same services. 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $120 copayment for emergency care. The enrollee has been asked to pay a $115.76 copayment, which is less than the standard $120 copayment, for the first emergency room visit. The enrollee has been asked to pay a $120 copayment for the second emergency room visit. The emergency room visits fall within the "Emergency 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 copayments for the emergency room visits provided on August 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for specialist services provided from May 2, 2019 to June 4, 2019.
You asked the Plan to waive the copayments for specialist services. You say that you disagree with the charges. 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 a $35 copayment for each specialist visit. You received specialist services provided from May 2, 2019 to June 4, 2019 for a total of 3 visits. The total amount you owe is: $35 (copayment) x 3 (specialist visits) = $105.00. You have been asked to pay the total copayment amount of $105.00 for specialist services. Specialist services fall within the physician/practitioner services, including doctor's office visits 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 copayments for specialist services provided from May 2, 2019 to June 4, 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 the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.
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 admission to an IRF does not meet criteria. Our physician reviewer found the enrollee was admitted to acute care on 11/25/19 following attempted implantable cardioverter-defibrillator (ICD) upgrade aborted due to perforation requiring open heart sternotomy for cardiac tamponade. Based on the documentation provided, the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to be able to perform fifteen hours per week of rehabilitative therapies. The enrollee's care needs can be met at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory test provided on August 26, 2019.
You asked the Plan to waive the copayment for the laboratory test. You say that laboratory testing should be included in your annual wellness visit and you should not have a copayment. 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 $20 copayment per visit for laboratory tests. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $20 copayment for the laboratory test.
You have been asked to pay a $14.88 copayment for the laboratory test. The laboratory test falls within "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 laboratory test provided on August 26, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve four periodontal scalings and root planings (code D4342).
You asked the Plan to pre-approve the scalings and planings. The Plan denied your request. The Plan says these services are not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
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 pre-approve four periodontal scalings and root planings (code D4342).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the deductible for the office visit provided on May 9, 2019.
You asked the Plan to waive the deductible for the office visit. You say that this was covered at the time of
service. The Plan denied your request. The Plan says that the deductible applied correctly.
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 enrollees must pay a $0 copayment for each Medicare-covered primary care
doctor office visit.
The Plan says you must pay $73.11 toward the deductible for the office visit. Based on the Plan contract,
however, you cannot be asked to pay more than a $0 copayment for the office visit. Your Evidence of
Coverage does not list a deductible amount that applies and clearly states there is a $0 copayment for primary
care office visits. Therefore, we decided that the Plan has to waive the cost for the office visit provided on May
9, 2019.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion or replacement of neurostimulator system for treatment of central sleep apnea; pulse generator only for the enrollee.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says published literature does not support these services at this time.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. There is currently insufficient evidence to show transvenous phrenic neurostimulation is reasonable and necessary for the treatment of illness. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion or replacement of neurostimulator system for treatment of central sleep apnea; pulse generator only for the enrollee.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One (J7325).
You asked the Plan to pre-approve Synvisc-One. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee has not tried Orthovisc and Monovisc as required by step therapy rules.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Synvisc-One. Our reviewer says that the criteria for coverage of Synvisc-One have not been met. Our physician reviewer found he Plan requires a trial of drugs Orthovisc and Monovisc first before they will approve the requested drug, Synvisc-One. The provided medical records do not indicate that the patient has tried and failed the required drugs or that the Plan's required drugs would likely be less effective or have adverse effects for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc-One have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc-One (J7325).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does nothave to pre-approve an office visit (99204) to be provided by out of network provider.You asked the Plan to pre-approvean office visit. You say that you are not satisfied with the care provided by the in-network physician that you saw on November 7, 2019 and want to return to the physician as he is familiar with your case.The Plan denied your request. The Plan says while it is understandable that you would prefer to use the same surgeon, unfortunately, the physician is not in the network. The Plan says that other surgeons are available in network who can provide the 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-approvecare 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-approvean office visit (99204) to be provided by out of network provider.