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

We decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network provider on April 27, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are available in-network.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network provider on April 27, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the radiology services provided from July 14, 2020, to September 29, 2020.

You asked the Plan to waive the coinsurance for the magnetic resonance imaging and ultrasound. You say that you cannot afford the coinsurance. The Plan denied your request. The Plan says they will remove one of the co-payments for date of service September 9, 2020 but you have been charged the remaining co-payments correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 co-payment for ultrasounds and a $250 co-payment for MRIs.

You have been asked to pay a $30 co-payment a $250 co-payment for each of the magnetic resonance imaging. The magnetic resonance imaging and ultrasound fall within the Outpatient Diagnostic tests 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 coinsurance for the radiology services provided from July 14, 2020, to September 29, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the lymphocyte mitogen response testing you received on December 8, 2020.

You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the coverage criteria are not met.

The Plan follows Medicare rules. Medicare rules say that lymphocyte mitogen response assays are covered when it is medically necessary to assess lymphocytic function in diagnosed immunodeficiency diseases and to monitor immunotherapy. 

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 testing. Our reviewer says that the requested testing is not medically reasonable and necessary. Our physician reviewer found that the enrollee had temperomandibular joint replacements in 1999 and requires revision. The requested test was to determine metal toxicity. The medical records do not indicate that the enrollee has a diagnosed immunodeficiency disease or that immunotherapy is being monitored. The elements of the coverage rule are not satisfied. 

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 testing have not been met. Therefore, we decided that the Plan does not have to pay for the lymphocyte mitogen response testing you received on December 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the flex-walk system (L5981) and multi-axial rotation
unit (L5986).

You asked the Plan to pre-approve the flex-walk system and multi-axial rotation unit. You say that the request
is medically necessary. The Plan denied your request. The Plan says the request exceeds your needs based on
functional level.

The Plan follows Medicare rules. Medicare rules say that these prosthetic items require a functional level of K3
or 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 the flex-walk system and multi-axial
rotation unit. Our reviewer says that the requested items are not medically reasonable and necessary. Our
physician reviewer found you are a 68-year-old who has a current K2 foot on the current prosthesis. There is an
appeal for a flex-walk system and multi-axial rotation unit. In this case, the physician medical progress notes
do not support that the patient's functional level is at a K3 or above.

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 flex-walk system and multi-axial rotation unit have not been met. Therefore,
we decided that the Plan does not have to pre-approve the flex-walk system (L5981) and multi-axial rotation
unit (L5986).
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. The Plan denied your request. The Plan says you do 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 you do not have documented skilled nursing or skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. Your care needs at this point are custodial and, as a practical matter, can be provided 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 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the total hip arthroplasty.

You asked the Plan to pay for the total hip arthroplasty.. You say that you would like reconsideration because the requested procedure is medically necessary. The Plan denied your request. The Plan says there is no documentation that the member has had a minimum 3-month trial of conservative treatment.

The Plan follows Medicare rules. Medicare rules say that Medicare will consider Total Hip Arthroplasty (THA) medically reasonable and necessary when the above criteria are met.

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 total hip arthroplasty. Our reviewer says that detailed documentation is not clearly evident regarding trial and failure of recent, reasonable and comprehensive less invasive conservative care measures over three months (to include anti-inflammatory medications, analgesics, or therapeutic injections when appropriate, along with physical therapy and/or assist devices.) Our physician reviewer found there is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to criteria.

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 total hip arthroplasty. have not been met. Therefore, we decided that the Plan does not have to pay for the total hip arthroplasty.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network provider form November 6, 2020, to November 13, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are available in-network.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network provider form November 6, 2020, to November 13, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on June 12, 2020 by an out of network (OON) provider.

You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.

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 lab work provided on June 12, 2020 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on September 5, 2020.

You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says the services
were billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that in the case where the beneficiary was
pronounced dead after the ambulance is called but before the ambulance arrives at the scene, providers must
report the A0428 (BLS) HCPCS code along with modifier QL.

We looked at the file and Medicare rules. The ambulance services in this case were not billed with the
appropriate HCPCS code and modifier. Based on this information, we decided that Medicare rules for coverage
of the ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for the
ambulance services provided on September 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the semi-electric hospital bed (E0261) and dry pressure
mattress (E0184) provided November 3, 2020.

You asked the Plan to pay for the semi-electric hospital bed and dry pressure mattress. You say that these items
were medically necessary for the enrollee. The Plan denied your request. The Plan says the criteria for these
items have not been met.

The Plan must follow Medicare rules. The rules say that the provider, supplier, or beneficiary, as appropriate,
must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the
amount of payment.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of these services have not been met. Specifically, there were no medical records provided in this case.
Without the medical records, we cannot review to see if the services were urgent/emergent or medically
necessary.

Therefore, we decided that the Plan does not have to pay for the semi-electric hospital bed (E0261) and dry
pressure mattress (E0184) provided November 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for core buildup, including any pins when required (D2950), and endodontic therapy, molar tooth (D3330) received September 19, 2019.

You asked the Plan to pay for the core buildup and endodontic therapy. You say that the requested services were necessary. The Plan denied your request. The Plan says you exceeded your annual maximum benefit allowance of $2500 prior to the services in dispute, therefore you are responsible for any remaining balance.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for core buildup, including any pins when required (D2950), and endodontic therapy, molar tooth (D3330).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion Spacer.

You asked the Plan to pre-approve the Vertiflex Superion Spacer. You say that you would like reconsideration because this procedure is medically necessary. The Plan denied your request. The Plan says this service is considered experimental and investigational as it is not identified as widely used and generally accepted for the proposed use.

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 Vertiflex Superion Spacer. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental and more research is needed to show its safety and efficacy.

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 Vertiflex Superion Spacer have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion Spacer.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound provided on November 25,
2020.

You asked the Plan to waive the copayment for an ultrasound. You say that there was no consultation before
the ultrasound. 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 $160
copayment for ultrasounds.

You have been asked to pay the allowed amount of $75.84, which is less than the $160 copayment for an
ultrasound. An ultrasound falls within the 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 an ultrasound provided on
November 25, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from December 10, 2020, to December 15, 2020.

You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you cannot afford the charges and thought that COVID-19 charges would be covered. 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 $393 copayment for days 1-5 for inpatient hospital care.

You had an inpatient hospital stay from December 10, 2020, to December 15, 2020. Therefore, you are responsible to pay a $393 copayment for days 1-4 (December 10, 2020, to December 14, 2020). $393 (copayment) x 4 (inpatient days) = $1,572.00.

You have been asked to pay the total copayment amount of $1,572.00 for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital care 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 an inpatient hospital stay provided from December 10, 2020, to December 15, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says the services of a licensed professional are not needed to provide 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 the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not qualify for SNF coverage. You do not have documented skilled nursing or skilled therapy needs. You are currently limited by your weight-bearing status. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. Your care needs at this point are custodial and, as a practical matter, can be provided 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 the admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the deductible for outpatient mental health care provided on January 26, 2021.

You asked the Plan to waive the deductible for outpatient mental health care. You say that you do not believe you should be responsible for the charges. The Plan denied your request. The Plan says that 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 does not say in clear and accurate terms that there is a $203 deductible. 

We looked at your contract with the Plan. We did not see where the contract says enrollees must pay a $203 deductible for outpatient mental health care. The Plan contract does not clearly say that there is a $203 deductible. This means that the Plan did not follow Medicare rules for disclosure of cost sharing information. Therefore, we decided that the Plan has to waive the deductible for outpatient mental health care provided on January 26, 2021.

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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the SNF admission.

You asked the Plan to pre-approve the SNF admission. You say that you would like reconsideration because the SNF admission is medically necessary. The Plan denied your request. The Plan says your needs can be met with intermittent physical and occupational three to four times per week.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the intermittent skilled services can be provided at a lower level of care than 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 SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve the SNF admission.