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

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.

You asked the Plan to pre-approve skilled nursing facility services. You say that the SNF admission is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

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 skilled nursing facility services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee's medical and functional needs are currently being met in an inpatient rehabilitation facility and can continue to be met there until the patient is ready for a transition to a home or community 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 skilled nursing facility services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide acute inpatient hospital care
You asked the Plan to provide acute inpatient hospital care. You say that the enrollee is in severe pain and needs surgery. The Plan denied your request. The Plan says the arthroplasty is approved but is not on the CMS Inpatient Only List.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 provide acute inpatient hospital care. Our reviewer says that the documentation does not support that inpatient care is medically necessary. Our physician reviewer found in this case, the enrollee is undergoing reverse arthroplasty of the shoulder. The medical record does not indicate that treating physician has a reasonable expectation of a length of stay spanning 2 or more midnights. The enrollee could be admitted for a period of observation and the decision to admit be made following that time. The elements of the coverage rule are not satisfied. The requested service is not recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to provide acute inpatient hospital care.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (88377, 88368, G0452) provided May 29, 2020.

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

We find that CPT code 88377, 88368, & G0452 is not supported in the medical record. Specifically, the records do not show these were separate and distinct services. These services are not eligible for unbundled payment. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (88377, 88368, G0452) provided May 29, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy provided by a participating provider on November 16, 2020.

You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that you do not agree with this copayment. The Plan denied your request. The Plan says the correct copayment has been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 copayment for outpatient surgery/in-network/outpatient hospital facility. 

You have been asked to pay a $200 copayment for a diagnostic colonoscopy. Evidence was provided to show that a polyp was found and removed. The rules say that, if during the course of the screening colonoscopy, a lesion or growth is detected which results in a biopsy or removal of the growth, the appropriate diagnostic procedure classified as a colonoscopy with biopsy or removal should be billed. A diagnostic colonoscopy falls within the outpatient surgery/in-network/outpatient hospital facility 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 a diagnostic colonoscopy provided by a participating provider on November 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health services to be provided by an out of network provider with an in-network exception.

You asked the Plan to pre-approve home health services with a network exception. You say that you are requesting a Gap Exception due to Network deficiency. The Plan denied your request. The Plan says you are not in need of services that are not available in the network.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan can pre-approve care from out-of-network providers but the cost to you may be higher. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these out-of-network services with an in-network Gap Exception. Therefore, we decided that the Plan does not have to pre-approve home health services to be provided by an out of network provider with an in-network exception.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says the enrollee does not have a complex condition requiring more than 25 days of continued inpatient hospital care.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our physician reviewer found that the enrollee was admitted to the acute care hospital for surgery for an ischemic bowel. Her hospital course was complicated by sepsis. She is receiving appropriate care at the present acute care hospital. She does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. Therefore, the requested LTACH services are 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 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: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Supartz FX.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the step therapy requirement is not met.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee has osteoarthritis. He has
not tried and failed the Plan's required drugs, Synvisc, Durolane, and Gelsyn-3. The records do not show that
the required drugs would be contraindicated or less effective; therefore, Supartz FX is not reasonable or
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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve Supartz FX.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the diphenhydramine and hydrocodone-acetaminophen provided in an outpatient setting from August 28, 2020, to August 29, 2020.
You asked the Plan to pay for the self-administered drugs. You say that you were sent to the emergency room. You say that you were not given any drugs or medication. You also say that you believe that the hospital is "double dipping." 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 diphenhydramine and hydrocodone-acetaminophen provided in an outpatient setting from August 28, 2020, to August 29, 2020.
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the services of home health/hospice aide in home health or hospice settings (G0156) provided from November 2, 2020, to December 18, 2020.

You asked the Plan to pay for the services of home health/hospice aide. The Plan denied your request. The Plan says the provider is not Medicare certified and not eligible to receive payment.

The Plan must follow Medicare rules. Medicare rules say that to receive payment for covered Medicare items or services, a provider or supplier must be enrolled in the Medicare program. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services of home health/hospice aide have not been met. This provider is not part of the Medicare program and is not payable. Therefore, we decided that the Plan does not have to pay for the services of home health/hospice aide in home health or hospice settings (G0156) provided from November 2, 2020, to December 18, 2020.
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 LTACH care is medically necessary. The Plan denied your request. The Plan says rules for LTACH care have not been met.
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 There is no documentation provided necessitating admission to an 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 he 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. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve partial upper dentures.
You asked the Plan to pre-approve dentures. You say that you are not able to eat. The Plan denied your request. The Plan says this service is not covered under your benefit package.
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. Although the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve partial upper dentures.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation visit to be provided at the in-network benefit level by an out-of-network (OON) provider.

You asked the Plan to pre-approve office visit. You say that you are requesting that this provider be considered in-network to perform surgery. The Plan denied your request. The Plan says the denial of authorization for in-network benefit level is correct, because this provider is out-of-network with the Plan and the enrollee can be treated by an in-network provider.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that enrollees may choose to receive care from out-of-network providers, but the cost for covered services may be higher. The Plan contract says that enrollees must pay $60 copayment for each out-of-network specialist visit. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services at the in-network benefit level. The enrollee may choose to see this provider at the out-of-network benefit level. Therefore, we decided that the Plan does not have to pre-approve a consultation visit to be provided at the in-network benefit level by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy provided by an out-of-network provider on
December 21, 2020.
You asked the Plan to pay for the psychotherapy. You say that you have been seeing this provider since 2016
and don't want to change this physician who already knows your condition. The Plan denied your request. The
Plan says the out-of-network services were not authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan 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 psychotherapy provided by an out-of-network
provider on December 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the treatment of root canal obstruction (D3331) and additional intraoral periapical x-ray (D0230) provided on April 16, 2020.
You asked the Plan to pay for the treatment of root canal obstruction and additional intraoral periapical x-ray. You say that you would like to appeal these services. The Plan denied your request. The Plan says the treatment of root canal obstruction is not covered under your dental plan. The Plan also says that your benefit plan has a limit for how often additional intraoral periapical x-rays are covered.
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, treatment of root canal obstruction (D3331) is not among those covered under this benefit. The contract also says that each additional intraoral periapical x-ray (D0230) is limited to once per year. The record shows that you received two additional intraoral periapical x-rays (D0230 x2) on April 16, 2020, one of which was covered by the Plan, and your additional intraoral periapical x-ray (D0230) benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the treatment of root canal obstruction (D3331) and additional intraoral periapical x-ray (D0230) provided on April 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the orthoses provided on September 25, 2020.

You asked the Plan to pay for the lumbar-sacral orthosis (L0650), the wrist hand orthosis (L3916), and the shoulder-elbow-wrist-hand orthosis (L3960). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the provider is not a Medicare certified Durable Medical Equipment supplier and therefore not eligible to receive payment.

The Plan must follow Medicare rules. The rules say no Medicare payment may be made to a beneficiary for items provided directly by a provider who is not eligible to take Medicare payment. 

The items at issue in this appeal were provided by a provider not certified by Medicare. Therefore, we decided that the Plan does not have to pay for the orthoses provided on September 25, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (84403, 84153, 82670, 842707) provided on November 17, 2020.

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were not pre-authorized. There were network providers available.

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 service 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 lab services (84403, 84153, 82670, 842707) provided on November 17, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on November 30, 2020 by a non-network provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by a non-network provider without 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 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 laboratory services provided on November 30, 2020 by a non-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from November 6, 2020, through November 17, 2020.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that he must pay a $325 copayment per admission for each medically necessary inpatient stay. If you are discharged from one level of care and readmitted to another level of care, separate copayments will apply. The enrollee has been asked to pay a $325 copayment for the inpatient hospital care provided. This means that the enrollee has been asked to pay the correct amount based on his contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay when he enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from November 6, 2020, through November 17, 2020.