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

We decided that the Plan does not haveto pre-approve admission to a skilled nursing facility (SNF).You asked the Planto pre-approvethe admission. You say that this is medically necessary.The Plandenied your request. The Plansaysthe care could be provided at a lower level of care.The Plan mustfollow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 admission have not been met.Therefore, we decided that the Plandoes not haveto pre-approveadmission to a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprovea pneumatic compression device (E0652).You asked the Plan to preapprovea 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 leastfour 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 preapprovea pneumatic compression device (E0652).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forchemotherapy administration (96413), and injections of pembrolizumab (J9271) provided from January 9, 2019 through March 13, 2019.You asked the Plan to waive the coinsurance forchemotherapy and injections. You say that you cannot pay this and need an adjustment from the Plan. No one ever explained billing for copayments of chemotherapy. The plan should adjust the amount of the copay. You have not received a diagnosis.The Plan denied your request. The Plan says outpatient diagnostic tests including radiation therapy have a 20% coinsuranceand Medicare Part B prescription drugs have a 20% coinsurance.Therules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for outpatient diagnostictestsand Medicare Part B prescription drugs. You have been asked to pay a 20% coinsurance for chemotherapy and injections. These servicesfall within the outpatient diagnostic tests benefit category. You received services on the following dates: January 9, 2019, February 20, 2019, and on March 13, 2019. The allowable amount for chemotherapy on January 9, 2019 was $10,287.90 x 20% = $2,057.58. The allowable amount for an injection on the same date of service$140.75 x 20% = $28.15($2,057.58+ $28.15= $2,085.73).The same total was applied on February 20, 2019. For date of service March 13, 2019, you were not charged a coinsurance for the same services rendered. Therefore, $2,085.73+ $2,085.73= $4,171.46. 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 forchemotherapy administration(96413), and injections of pembrolizumab (J9271) provided from January 9, 2019 through March 13, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for interpreting physician's services for an ultrasound provided on August 17, 2019.You asked the Plan to pay for the interpreting physician's services.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 payfor these services. Therefore, we decided that the Plan does not have to pay for interpreting physician's services for an ultrasound provided on August 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran epidural injection procedure provided on August 20, 2019.You asked the Plan to waive the copayment foroutpatient surgery. You say that you have not had to pay this amount for previous procedures, and you were never in a hospital.The Plan denied your request. The Plan says the copayment amount you are being charged is correct.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 $225 copayment for in-network outpatient surgery at an outpatient hospital. The epidural procedure performed is considered to be a surgical service, and the provider is considered to be an outpatient hospital facility.You have been asked to pay $225 copayment for outpatient surgery. Outpatient surgery 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 thePlan. 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 foran epidural injection procedure provided onAugust 20, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvepositron emission tomography (PET) scan services.You asked the Plan to pre-approvethe PET scan services. You say that the enrollee needs the requested PET scan because it is sensitive to finding lymphoma.The Plan denied your request. The Plan says the medical records provided do not support that the guidelines for coverage have been met.The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically 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 PET scan services. Our reviewer says that a PET scan is not medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a history of non-Hodgkin's lymphoma and that the PET/CT is wanted for surveillance purposes. Our physician reviewer found that the NCCN guidelines says that reimaging with CT scans is clinically indicated.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 PET scan services have not been met.Therefore, we decided that the Plan does not have to pre-approvepositron emission tomography (PET) scan services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye exam on September 6, 2019.You asked the Plan to waive the copayment forthe eye exam. You say that they misdiagnosed you. You say that you shouldn't have to pay a 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 $15 for each Medicare-covered outpatient visit for services to diagnose and/or treata disease or condition of the eye.You have been asked to pay a $15 copayment for the eye exam. The eye exam falls within the "Vision care" benefit category. The records show that a medical eye exam was performed. 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 eye exam on September 6, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forcataract surgery provided on September 10, 2019.You asked the Plan to waive the copayment forcataract surgery. You say that you were told by a customer service representative that you would not have to pay anything for these services except for a $25 copayment.The Plan denied your request. The Plan says the copayment amount you are being charged is correct.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 $250 copayment for cataract surgery at an outpatient hospital. You have been asked to pay $250 copayment for cataract surgery. Cataract surgery 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 forcataract surgery provided on September 10, 2019.Your complaint regarding receiving inaccurate information about the cost-share for this service is considered to be a grievance. We do not have the jurisdiction to address grievances. Please contact the Plan for more information about your grievance.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on February 12, 2019.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you must receive care fromin-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 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 physician's services provided on February 12, 2019.
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-approvethe LTACH services. You say that the enrollee requires wound care, physician monitoring, and rehab therapies.The Plan denied your request. The Plan says the enrollee has no need for active management or treatment of 2 comorbid conditions.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) for a recurrent pleural effusion related to radiation received for breast cancer. The enrollee received a chest tube, TPA infusions and pleurodesis. The current plan is to leave the chest tube in upon discharge. The enrollee is not intubated/ventilated. 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-approvelong term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6549.You asked the Plan to pre-approve the compression stockings. You say that the stockings were prescribed and should be covered.The Plan denied your request. The Plan says the stockings are noncovered.The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan.Therefore, we decided that the Plan does not have to pre-approvecompression stockings identified with code A6549.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.You asked the Plan to pre-approve a shower chair. You say that while showering you are unable to lift your legs or bathe correctly due to shortness of breath. You say that you need the shower chair in order to maintain proper hygiene. Additionally you said that you have shortness of breath and low oxygen levels.The Plan denied your request. The Plan says this item is not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.Therefore, we decided that the Plan does not have to pre-approvea shower chair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the requested admission to an IRF is medically necessary.The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.The Plan must follow Medicare rules.The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested admission to an IRF does not meet criteria. Our physician reviewer found the enrollee was admitted to acute care on 1/8/20 for chronic obstructive pulmonary disease (COPD) exacerbation, acute respiratory distress, and chronic changes without acute findings on chest x-ray. The recent medical records indicate the enrollee is improving, and hemodynamically stable. Oxygen needs are 3-liters via nasal cannula. The enrollee is debilitated and mostly minimal assist/supervised for transfers and gait for short distances and with use of a walker. The enrollee is cachectic and has disuse weakness per records. Nutrition needs to be optimized given pulmonary issues. Records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a lower level of care. Ongoing pain medication and other medication management, skin and O2 care, and daily therapy can be provided at a lower level of care. In this case, the enrollee is mostly minimal/standby assist for functional transfers and activities of daily living 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forSNF care provided to the enrollee from May 3, 2019 through May 28, 2019 by an out-of-network provider.You asked the Plan to waive the copayment forSNF care. You say that you are appealing the member's cost-share responsibility for the services the member received.The Plan denied your request. The Plan says the claim was processed accordingly with the member's 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 show that the enrollee received SNF care from May 3, 2019 through May 28, 2019 by an out-of-network provider. The enrollee is asked to pay 30% coinsurance for the out-of-network SNF care. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forSNF care provided to the enrollee from May 3, 2019 through May 28, 2019 by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary partial denture.You asked the Plan to pre-approvethe maxillary partial denture. You say that you would like new dentures to be made that will be of better quality.The Plan denied your request. The Plan says your dentist is not in the Plan's provider network. The Plan also says that services are only covered by your Health Plan for in-network dentists.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 when they are rendered by an out-of-network provider.Therefore, we decided that the Plan does not have to pre-approvea maxillary partial denture.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea FreeStyle Libre continuous glucose monitoring system.You asked the Plan to pre-approvea FreeStyle Libre continuous glucose monitoring system. You say that  The Plan denied your request. The Plan says criteria for a CGM have not been met.The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor.We looked at the file, and Medicare rules. There are no data logs of BGM testing and the recorddoes not show your insulin treatment regimen requires frequent adjustment on the basis of BGMtesting results. Based on this information, we decided that Medicare rules for coverage of a FreeStyle Libre continuous glucose monitoring system have not been met.Therefore, we decided that the Plan does not have to pre-approvea FreeStyle Libre continuous glucose monitoring system
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay forthe emergency department services providedon August 9, 2019.You asked the Plan to pay forthe emergency department services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are a duplicate.The Plan mustfollow 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 99284 is emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high severity, and require urgent evaluation by the physician, or other qualified health care professionals but do not pose an immediate significant threat to life or physiologic function.We find that CPT code 99284 is not supported in the medical record. Specifically, a code representing the same service (CPT 99285) has been reported for the same date of service. The documentation supports that both emergency visits were for the same reason, therefore, only one is payable. Based on this information, we decided that Medicare rules for coverage of the emergency department services have notbeen met.Therefore, we decided that the Plan does not have to pay forthe emergency department services provided on August 9, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prefabricated post and core (code D2954) provided on April 26, 2019.You asked the Plan to pay forthe post and core. You say that you weretold that this dentist was out-of-network but had a claim paid last year for this same provider and you were not told that he was out-of-network at the time of service.The Plan denied your request. The Plan says your coverage only provides for this service when performed by a participating network provider. The Plan also says that this provider is out-of-network.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 covered when they are received out-of-network.Therefore, we decided that the Plan does not have to pay forthe prefabricated post and core (code D2954) provided on April 26, 2019.