Persius/hicric huggingface dataset:
Appeal type: ER
Decision: Favorable

We decided that the Plan has to pay forCPT code 99283 provided on December 18, 2019.You asked the Plan to pay forCPT code 99283. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says that the services are not covered.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. Specifically, the Plan denied payment for the emergency room services stating that the diagnosis is inconsistent with the procedure. However, the Plan has not provided any supporting documentation that shows why the billed services could not be paid per Medicare guidelines.Therefore, we decided that the Plan has to pay forCPT code 99283 provided on December 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on January 4, 2019.
You asked the Plan to waive the copayment for the office visit. You say that you disagree with the amount owed. The Plan denied your request. The Plan says the services were processed correctly per your plan 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). Your contract with the Plan clearly says that you must pay a $65 copayment for provider and professional services provided by an out of network provider. You have been asked to pay a $65 copayment for the office visit. The office visit falls within the physician/practitioner 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 office visit provided on January 4, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids purchased November 25, 2019.You asked the Plan to pay for the hearing aids. You say that you were told that if you went out of network you could fill out forms to be reimbursed. The benefit book shows a $1000 allowance but says nothing about having to go to in-network providers.The Plan denied your request. The Plan says hearing aids must be obtained from an in-network provider.Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when provided from an in-network provider. On page 51 of the health plan contract says enrollee's must receive their services from an in-network provider. Non-emergent services with non-contracted providers require prior-authorization prior to services being rendered.  We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met.Therefore, we decided that the Plan does not have to pay for the hearing aids purchased November 25, 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 enrollee needs to be transferred to regain maximum prior level of functioning and continue a multi-disciplinary approach to care.The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient care, and does not require transfer.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 physician reviewer found that the enrollee is currently undergoing treatment at an acute care hospital (ACH) following surgery for a bowel obstruction. His post-operative course was complicated by a heart attack and renal injury. The enrollee is not currently intubated/ventilated.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.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: 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. The Plan denied your request. The Plan says the enrollee is clinically unstable, and she is getting care at the acute 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 physician reviewer found that the enrollee was undergoing treatment at an acute care hospital (ACH) for lower extremity cellulitis and wounds. The enrollee was not intubated/ventilated. There is no evidence that the enrollee required the services provided at a LTACH, at the time of discharge. 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forhome health care services provided by a home health agency that does not participate in Medicare from July 17, 2019 to August 17, 2019.You asked the Plan to pay forhome health care services. You say that this should be covered.The Plan denied your request. The Plan says these services were provided by a provider who does not participate in Medicare.The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare program.We looked at the file and Medicare rules. The provider of these services does not participate in the Medicare program. Based on this information, we decided that Medicare rules for coverage of home health care services have not been met.Therefore, we decided that the Plan does not have to pay for home health care services provided by a home health agency that does not participate in Medicare from July 17, 2019 to August 17, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient facility services provided on October 12, 2019.
You asked the Plan to pay for the outpatient facility services. The Plan denied your request. The Plan says nonemergent,
non-urgent services with out-of-network providers require prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we
decided that the Plan does not have to pay for outpatient facility services provided on October 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network provider on January 30, 2020.You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.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 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 medical services provided to you by an out-of-network provider on January 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for infrared therapy provided from October 22, 2019 to November 25, 2019.You asked the Plan to pay for the infrared therapy. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for infrared therapy provided from October 22, 2019 to November 25, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa injections.
You asked the Plan to pre-approve Euflexxa. You say that Euflexxa is medically necessary. The Plan denied
your request. The Plan says a trial of Orthovisc and Monovisc is required before alternatives can be considered.
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 Euflexxa. Our reviewer says that
coverage criteria has not been met. Our physician reviewer found the record does not show that the plan's
preferred drugs were trialed. The record does not show any reason why the plan preferred drugs would be
ineffective or unsafe for this 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have
to pre-approve Euflexxa injections.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered on December 17, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the provider is not licensed to perform the services.
The Plan must follow Medicare rules. The rules say that the issuance by a State of a license to practice medicine constitutes legal authorization. We looked at the file and Medicare rules. The file shows that the provider was not licensed to practice for the date of service at issue. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the services rendered on December 17, 2019.
Appeal type: Imaging
Decision: Unfavorable

e decided that the Plan does not have to waive the copayment forthe CT scan provided on January 8, 2020.You asked the Plan to waive the copayment forthe CT scan. You say that this procedure should have been coded as an LDCT screening for lung cancer with no cost share. 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 $160 copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a physician's officeor at a free-standing facility (such as a radiology center or medical clinic). For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $160 copayment for the CT scan.You have been asked to pay a $154.09 copayment for the CT scan. The CT scan falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. The medical record shows this CT scan was a follow-up to an LDCT screening. Please note, there is no provision in the contract which indicates a copayment would be waived if performed as a follow-up to an LCDT screening.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 CT scan provided on January 8, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 21, 2019.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the claim was processed correctly.
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 99254 is inpatient consultation for a new or established patient. We find that CPT code 99254 is not valid for Medicare purposes. Medicare uses another code for the reporting of, and payment for, these services. 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 pay for the medical services provided on July 21, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the full cost of the contact lenses.
You asked the Plan to pay for the contact lenses. You say that the lenses should be covered. The Plan denied
your request. The Plan says it has paid the $175 allowance on the $240 total bill. The remaining $65 is the
enrollee's responsibility.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case.
We looked at the file and the Plan's rules. The $240 total for the contact lenses exceeds the $175 allowance
provided. Based on this information, we decided that the Plan's rules for coverage of the contact lenses have
not been met. Therefore, we decided that the Plan does not have to pay for contact lenses (V2520) provided
December 6, 2019, beyond the $175 allowance already paid.
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 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 IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at a SNF. In this case, the enrollee is mostly maximum assist for functional transfers and activities of dailyliving (ADL's) and a less intensive, longer duration of therapy may be more appropriate. It is not clear the enrollee would be able to fully benefit and/or participate in an IRF 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for inpatient hospital services provided April 10, 2019 to November 18, 2019.You asked the Plan to waive the copayments for the inpatient hospital services. You say that the copayments should be waived.The Plan denied your request. The Plan says the correct copayments were applied.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $225 per day copayment for days 1-5 for Inpatient Care. You have been asked to pay copayments of $225 per day for 3 separate inpatient admissions up to the maximum allowable amount. 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 inpatient hospital services provided April 10, 2019 to November 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 5, 2019 by an out of network (OON) provider.You asked the Plan to pay for ophthalmology services. You say that the provider was unaware of the enrollee's insurance at the time of service.The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and 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 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 forthe medical services provided on September 5, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the deductible for the office visit provided on February 20, 2020.You asked the Plan to waive the deductible for the office visit. You say that this was an office visit and shouldn't have applied the deductible. You say that you have always been required to pay a copayment.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 the deductible applies to individual or group therapy visits. Your contract with the Plan says that the deductible does not apply to primary care physician or specialist visits.The Plan says you must pay $93 toward the deductible for the office visit. Based on the Plan contract, however, you cannot be asked to pay more than a $35 copayment for the office visit.According to the Plan contract, the outpatient mental health benefit is for individual or group therapy visits. The records show that a regular office visit was billed, which is considered a specialist visit. Therefore, we decided that the Plan has to waive the deductible and apply a $35 copayment for the office visit provided on February 20, 2020.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 a powered upper extremity range of motion assist device.
You asked the Plan to pre-approve a powered upper extremity range of motion assist device (L8702). You say that this device would restore function to the dysfunctional arm and the ability to perform activities of daily living. The Plan denied your request. The Plan says Medical studies haven't proven that the device is helpful for treatment of the enrollee's clinical scenario.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary, and are experimental and investigational, are not covered. We looked at the file and Medicare rules. There is insufficient medical record information submitted to show this orthosis would be preferred or more effective than the traditional upper orthosis types that are covered by Medicare. Based on this information, we decided that Medicare rules for coverage of a powered upper extremity range of motion assist device (L8702) have not been met. Therefore, we decided that the Plan does not have to pre-approve a powered upper extremity range of motion assist device