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

We decided that the Plan does not have to waive the copayment for the tibial neurostimulation provided on November 13, 2019.You asked the Plan to waive the copayment for the tibial neurostimulation. You say that this is not a surgical procedure. You say that you have always been charged a $45 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 $295 copayment for Medicare-covered, in-network outpatient hospital services.You have been asked to pay $257, which is less than the standard $295 copayment for the tibial neurostimulation. The tibial neurostimulation 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 tibial neurostimulation provided on November 13, 2019
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Nebusal for the enrollee.You asked the Plan to pre-approveNebusal. You say that the patient is showing tolerance and controlling symptoms well on this medication.The Plan denied your request. The Plan says that that this is not covered by Medicare.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. The plan has not provided any medical records for this appeal.Without this documentation our office is unable to determine medical necessity and whether or not the plan's denial was correct.Therefore, we decided that the Plan has to pre-approveNebusal for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from August 16, 2019 to September 14, 2019.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee did not require any skilled services that could not have been provided in an alternate setting other than a SNF.
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 pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting.
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 skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from August 16, 2019 to September 14, 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 it is felt that IRF care would be the best option.The Plan denied your request. The Plan says the criteria for coverage of IRF care are not 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 the enrollee recently underwent elective spinal surgery. The post-operative course has included management of pain. The enrollee is tolerating medications. There is no fever, or signs of wound infection or toxicity. Records do not indicate that there are significant, or complex medical/nursing issues that a hospital level of care. In this case, the enrollee requires mostly minimal assist for functional transfers and ADLs and a less intensive, longer duration of therapy can allow for measurable gains to be attained within a predicted period.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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Denosumab/Prolia for the enrollee.You asked the Plan to pre-approve the drug. You say that this is medically necessary.The Plan denied your request. The Plan says the notes show that the last test for osteoporosis did not show osteoporosis.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 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 drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the reviewed records do not include a DEXA scan or other supporting documentation for the diagnosis of osteoporosis. Without the support of the documentation, medical necessity for the use of Prolia is not determined.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 drug have not been met.Therefore, we decided that the Plan does not have to pre-approve Denosumab/Prolia for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea pneumatic compression device (E0652) and segmental pneumatic appliance/sleeve (E0667).You asked the Plan to pre-approvea pneumatic compression device and sleeve. You say that you understand that coverage was denied as not medically necessary and respectfully disagree.The Plan denied your request. The Plan says the enrollee has not had a failed 4 week trial with E0650 or E0651. Therefore, E0667 is non-covered when requested in conjunction with the non-approved code E0652.The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least fourweeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses theappliance provided.Therefore, we decided that the Plan does not have to pre-approvea pneumatic compression device (E0652) and segmental pneumatic appliance/sleeve (E0667).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a pneumatic compression device (E0652).You asked the Plan to preapprove a pneumatic compression device. You say that the enrollee requires the device.The Plan denied your request. The Plan says the documentation did not support the 4-week trial using the basic pump that Medicare requires.The Plan follows Medicare rules.The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided.Therefore, we decided that the Plan does not have to preapprove a pneumatic compression device (E0652).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy (90833, 99213) provided August 30, 2018.You asked the Plan to pay forthe outpatient mental health services. You say that the services should be covered.The Plan denied your request. The Plan says the claim was not submitted to the health plan within the allowable timeframe.The Plan follows Medicare rules. The rules say that claims for servicesfurnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service.The record shows that a claim for the outpatient mental health services was not filed until December 2, 2019. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay forpsychotherapy (90833, 99213) provided August 30, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services provided to you by a Medicare opt-out provider on July 25, 2019, and July 31, 2019.You asked the Plan to pay forthe services. You say that these services have been covered before.The Plan denied your request. The Plan says this provider has opted out of Medicare.The Plan must follow Medicare rules. The rules say that no Medicare payment may be made toa beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.The services at issue in this appeal were provided in a non-urgent, non-emergent situation by a provider who has opted out of the Medicare program. The file shows that this provider entered into a private contract with you regarding payment.Therefore, we decided that the Plan does not have to pay forthe services provided to you by a Medicare opt-out provider on July 25, 2019, and July 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pay for anesthesia services provided to the enrollee on August 28, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysminor pain procedures under most circumstances do not require anesthesia care other than local anesthesia.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 relevantMedicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not medically reasonable or necessary. Our physician reviewer found medical necessity for ananesthesiologist to administer MAC was not established. The review has determined that the services at issue in this case were not medically reasonable and necessary. According to guidelines from the American Society of Anesthesiologists and the International Spine Intervention Society, minor pain procedures under most routine circumstances do not require anesthesia care other than local anesthesia.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 Plandoes not haveto pay foranesthesia services provided to the enrollee on August 28, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says he rehabilitation needs are not complex enough to require coordinated care between therapy disciplines.
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 the enrollee's medical conditions appear stable. There are no wound care needs. There are no unaddressed medical issues. She does not require medical oversight of her condition at an acute hospital level of care. There is no reason to think that an intensive rehabilitation therapy program would significantly impact the enrollee's condition differently compared with therapy provided at a less intense level. The enrollee's care can be appropriately provided at an alternate level of care including through home-based and outpatient services. 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for physician's services provided on April 21, 2019.You asked the Plan to pay for the physician's service. You say that the Plan does not have participating providers that make rounds the enrollee was assigned to see this physician who is authorized to see patients at this facility. The Plan denied your request. The Plan says that the enrollee must receive care from in-network providers with the exception of emergency or urgent care, or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan. 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.The enrollee wasreferred for the physician's service. The provider is a contract providerwith the Plan. The file does not show that the Plan provided notice that the physician's servicewould not be coveredprior to the service being rendered. Under Medicare rules, this means the physician's serviceisconsidered approved by the Plan. Therefore, we decided that the Plan has to pay for the physician's serviceprovided on April 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe Orthovisc injection provided on September 24, 2019.You asked the Plan to waive the coinsurance forthe Orthovisc injection. You say that you have been charged less for the same procedure. You say that you are wondering why you are charged so much.The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for Medicare Part B covered drugs. You have been asked to pay $162.14, which is 20% of the allowed amount for the Orthovisc injection. The allowed amount is $810.68 (20% x $810.68 = $162.14). The Orthovisc injection falls within the "Medicare Part B prescription drugs" 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 decidedthat the Plan does not have to waive the coinsurance forthe Orthovisc injection provided on September 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the office visits provided on August 19, 2019 and October 3, 2019.
You asked the Plan to waive the cost share for the office visits. You say that you paid the $35 copayment the office asked for. You say that you are receiving bills for the doctor being out-of-network but the office is in-network. The Plan denied your request. The Plan says the cost share 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 your deductible is $975 for some in-network and out-of-network services. This is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. Out-of-network specialist visits are not excluded from the deductible. Your contract with the Plan also says that you must pay a $50 copayment for each out-of-network specialist visit. The item or service you asked the Plan to waive the cost share for falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $975 deductible applies to out-of-network specialist visits. This cost sharing is a contractual obligation that had not been met at the time the office visit was received on August 19, 2019.
Since your $975 deductible was met, you have also been asked to pay a $50 copayment for the office visit provided on October 3, 2019. The records show that the provider is out-of-network. 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 share for the office visits provided on August 19, 2019 and October 3, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forinpatient hospital care from August 4, 2019 through August 9, 2019 provided by an in-network provider.You asked the Plan to waive the copayment forinpatient hospital care. You say that you are appealing your cost-share responsibility for the services you received.The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file shows that you were admitted on August 4, 2019 and discharged on August 9, 2019. You were asked to pay a $150 copayment per day from August 4, 2019 through August 7, 2019, days 1-4 of your inpatient stay. There were no copayment charges from August 8, 2019, day 5 of your inpatient hospital care until your day of discharge August 9, 2019. Per your contract there is a $150 copayment per day required for days 1-4. 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 forinpatient hospital care from August 4, 2019 through August 9, 2019 provided by an in-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe preventive medicine counseling (CPT 99412) you received on October 1, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the benefit limit has been exceeded.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 youmust pay a $0 copayment for wellness programs up to 6 visits per year. Review of the file shows that you had a preventive medicine counseling visit on October 1, 2019. The records show that you already received six covered visits for the 2019 calendar year. This means that the requested visit exceeds the benefit limit. This means that you have been asked to pay the correct amount based on your contract with the Plan.Therefore, we decided that the Plan does not have to pay forthe preventive medicinecounseling (CPT 99412) you received on October 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care rendered on August 26, 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 procedure code 99231 is not separately payable.
The Plan must follow Medicare rules. The rules say that all additional medical or surgical services required of the surgeon during the postoperative period of the surgery because of complications which do not require additional trips to the operating room are included in the global surgical package. We looked at the file and Medicare rules. The services at issue are subsequent hospital care provided within the global surgical period for prior surgical procedure billed with code 47562. Payment for these services is included in the global surgical package. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care renderedon August 26, 2019.