Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an LSO (L0650) provided on September 14, 2020.

You asked the Plan to pay for an LSO. You say that the requested item is medically necessary for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met because there is no documentation of a video or telephonic visit by the ordering physician to warrant the code billed.

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 pay for an LSO. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee's chief complaint was lower back pain. The available documentation in the case file does not support that the requested LSO was medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by Medicare. An appropriate history and a physical examination of the back would reasonably be required to adequately assess whether the coverage criteria for an LSO have been met. The documentation does not support that the LSO was prescribed for one or more of the covered indications in this case, as there is insufficient documentation of an appropriate evaluation of the enrollee and insufficient documentation of a credible physical examination of the back.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an LSO have not been met. Therefore, we decided that the Plan does not have to pay for an LSO (L0650) provided on September 14, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services (90832) provided on September 24, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the psychotherapy services. You say that you would like reconsideration because the physician provided medically necessary services to the member in good faith. The Plan denied your request. The Plan says authorization for out of network services 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 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 psychotherapy services (90832) provided on September 24, 2020 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that inpatient skilled nursing facility care is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of inpatient skilled nursing facility care.
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 inpatient skilled nursing facility care is not medically necessary. Our physician reviewer found that the enrollee has stabilized medically and is ready for discharge from the hospital. The enrollee does not require skilled nursing and/or skilled therapy services on a daily basis. She is medically stable and can receive further rehabilitation services at a lower level of care. Although further rehabilitation services would be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a skilled nursing facility. The enrollee does not have any parental medication; complex wound care or nutrition given via a feeding tube. She is medically stable without any acute exacerbations of chronic medical problems. Her physical function is at or near her baseline and she can receive services at a lower level of care. Admission to a SNF for inpatient skilled rehabilitation services is not medically 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab testing (82607, 82746) provided December 21, 2020.
You asked the Plan to pay for the lab testing. You say that the services were medically necessary. The Plan denied your request. The Plan says these services were already paid 3 times each. The number of tests performed exceeds the allowed amount.
The Plan must follow Medicare rules. Medicare rules say that CPT codes 82607 and 82746 are only covered up to 3 times a year. We looked at the file and Medicare rules. CPT codes 82607 and 82746 were already paid 3 times in 2020. The billed services exceed the allowed amount. Based on this information, we decided that Medicare rules for coverage of the lab testing have not been met. Therefore, we decided that the Plan does not have to pay for lab testing (82607, 82746) provided December 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397).
You asked the Plan to pay for the knee orthosis and suspension sleeve. You say that the items provided were medically necessary. The Plan denied your request. The Plan says the patient did not receive a video or telephonic visit by the ordering physician in order to warrant the codes billed.
The Plan follows Medicare rules. Medicare rules say that the knee orthosis and suspension sleeve are subject to the criteria listed 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 pay for the knee orthosis and suspension sleeve. Our reviewer says that the requested items were not medically reasonable and necessary. Our physician reviewer found there is insufficient documentation of an appropriate evaluation of the enrollee, and there is insufficient credible objective documentation of joint laxity. In addition, the item coded L2397 (sleeve) is not separately payable when the base item is not covered. 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 knee orthosis and suspension sleeve have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397).
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 from July 20, 2020, to July 21, 2020.
You asked the Plan to pay for the self-administered drugs. You say that you were in the hospital for a knee replacement. 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 from July 20, 2020, to July 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an injection (20601, J3301) provided on September 24, 2020 by an out of network (OON) provider.
You asked the Plan to pay for an OON injection. You say that a previous visit with this provider was covered. The Plan denied your request. The Plan says this service was 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 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 an injection (20601, J3301) provided on September 24, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided May 18, 2020.
You asked the Plan to pay for the genetic testing. You say that the services were medically necessary. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. Medicare rules say that diagnostic laboratory tests using Next Generation Sequencing must have Food & Drug Administration (FDA) approval or clearance as a companion in vitro diagnostic. We looked at the file and Medicare rules. In this case, the test at issue is not listed as an FDA approved in-vitro diagnostic. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing provided May 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor and supplies.
You asked the Plan to pre-approve a therapeutic continuous glucose monitor and supplies. You say that this device is medically necessary for your condition. The Plan denied your request. The Plan says the criteria for a therapeutic continuous glucose monitor has 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. We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a therapeutic continuous glucose monitor and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor and supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a scooter and accessories purchased July 31, 2020, from a provider that is not certified with Medicare.

You asked the Plan to pay for a scooter and accessories. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says the provider is not included in the Medicare Supplier Directory as a certified provider.

The Plan must follow Medicare rules. Medicare rules say that a provider must be enrolled in the Medicare program for services to be rendered. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a scooter and accessories have not been met. Therefore, we decided that the Plan does not have to pay for a scooter and accessories purchased July 31, 2020, from a provider that is not certified with Medicare.
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 you are in great pain and discomfort. The Plan denied your request. The Plan says there is no documentation that you will benefit from and improve with LTACH management.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the short-term acute care hospital can provide for all of the patient's present inpatient care needs and the patient is receiving an appropriate level of care in the present setting. The short-term acute care hospital can provide for all of the patient's present inpatient care needs and the health plan has stated that continued care in the short-term acute care hospital will be covered. The patient is presently receiving these services in the short-term acute care setting. Continued care in the short-term acute care hospital is appropriate until the patient is stable to transfer to a lower level of care such as an inpatient rehabilitation facility, a sub-acute rehabilitation facility or a skilled nursing facility. 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 LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that you would like the plan to reconsider
their denial The Plan denied your request. The Plan says the requested admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee's hospitalization was complicated by hypotension treated with midodrine,
ascites requiring four paracenteses, a moderate sized pleural effusion and anemia. There is no documentation
provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute
care hospital. The enrollee does not require services at the LTACH that are not available at the acute care
hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee
requires that are not available at the health care setting being offered by the health plan.
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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on October 12, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says generally you must receive care from a network provider. In most cases, care you receive from an out-of-network provider (a provider who is not part of our Plan's network) will not be covered.
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 physician's services. 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 physician's services provided on October 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost shares for the outpatient surgery services provided on November 9, 2020, and November 23, 2020.

You asked the Plan to waive the cost shares for the services provided. You say that you cannot choose where the doctor does surgery. The Plan denied your request. The Plan says the claims 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 40% coinsurance for out-of-network outpatient surgery. 

You have been asked to pay a 40% coinsurance for the services provided on each date at issue. The services fall within the out-of-network outpatient surgery 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 cost shares for the outpatient surgery services provided on November 9, 2020, and November 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the extraction, erupted tooth requiring removal of bone and/or sectioning of tooth (D0210).
You asked the Plan to waive the coinsurance for the tooth extraction. You say that you were not aware the provider was no longer considered in-network. The Plan denied your request. The Plan says when receiving out-of-network care you will be responsible for the difference between the Plan's in-network rate and what the out-of-network provider charged, therefore the correct cost share applied to the claim.
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 0% coinsurance for teeth extractions, however you are responsible for the difference between the Plan's contracted in-network rate and what the out-of-network provider charges for the covered items or services. You have been asked to pay $51 in coinsurance for the tooth extraction. This amount is the difference between the Plan's in-network contracted rate and the amount charged by the out-of-network provider This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the extraction, erupted tooth requiring removal of bone and/or sectioning of tooth (D0210).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance ride provided on January 13, 2021.
You asked the Plan to waive the copayment for the ambulance ride. You say that you had fallen due to COVID and you should not be charged a copayment. The Plan denied your request. The Plan says you have been asked to pay 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 $200 copayment for each Medicare-covered ground ambulance service. You have been asked to pay a $200 copayment for the ambulance ride. The ambulance ride falls within the "Ambulance services" benefit category. The record shows you did not have a fever or COVID symptoms when you experienced the syncopal episode, and the record shows no COVID-related diagnosis codes. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance ride provided on January 13, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on September 14, 2020.
You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says non-emergent, 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 psychotherapy services provided on September 14, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the injection provided on November 11, 2020.
You asked the Plan to waive the copayment for the injection. You say that you have always gone to this doctor and have never received a $200 copayment for the visit. The Plan denied your request. The Plan says you have been asked to pay 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 $200 copayment per visit for Medicare-covered outpatient surgery in an ambulatory surgical center or hospital outpatient facility. You have been asked to pay a $200 copayment for the injection. The injection falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 injection provided on November 11, 2020.
Your complaint about the benefit design is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.