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

We decided that the Plan does not have to pre-approve additional routine transportation trips.

You asked the Plan to pre-approve additional routine transportation trips. You say that the enrollee needs more
trips to get to appointments. The Plan denied your request. The Plan says the enrollee has one trip remaining,
and further trips cannot be approved.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this
case. The Plan covers a maximum of 32 trips per year.

We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that the requested additional trips exceed the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on March 10, 2021.

You asked the Plan to pay for the services provided. You say that you were not aware the office was out-of-network. The Plan denied your request. The Plan says benefits were applied correctly.

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.

We looked at the file, and Medicare rules. The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the dental 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 dental services provided on March 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office visits to be provided by an out-of-network (OON)
orthopedic surgeon.

You asked the Plan to pre-approve office visits with an orthopedic surgeon. You say that you were told this
would be authorized. The Plan denied your request. The Plan says this is 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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.

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. Therefore, we decided that the Plan does not have to pre-approve
office visits to be provided by an out-of-network (OON) orthopedic surgeon.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on January 11, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the OON services. The Plan denied your request. The Plan says out-of-network services require 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 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 office visit provided on January 11, 2021 by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the abdominal aortic aneurysm screening you received on February 8, 2021.

You asked the Plan to pay for the screening. 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 you must pay a $0 copayment for one abdominal aortic aneurysm screening per lifetime. 

Review of the file shows that you were provided an abdominal aortic aneurysm screening on February 8, 2021. The records also show that you had a covered abdominal aortic aneurysm screening on March 12, 2018. This service is only covered once per lifetime. This means that the requested screening is your second, which 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 for the abdominal aortic aneurysm screening you received on February 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation.

You asked the Plan to pre-approve the requested services. You say that nothing else has alleviated the
enrollee's pain. The Plan denied your request. The Plan says the services are unproven for the treatment of knee
pain.

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 requested services. Our physician
reviewer found that the enrollee has osteoarthritis of the knees. She has tried physical therapy, platelet-rich
plasma injections, and takes Tylenol and Motrin for pain. She is deemed not to be a surgical candidate. The
requested service is considered an experimental/investigational procedure. It is the subject of ongoing clinical
trials to determine its role in the treatment of osteoarthritis of the knee. Therefore, the request is considered not
medically reasonable or 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 requested services have not been met. Therefore, we decided that the Plan
does not have to pre-approve genicular nerve radiofrequency ablation.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (Guardant360) provided to the enrollee on March 9, 2020.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says this is experimental and investigational, as it is not FDA-approved.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case there was no clinical rational for Guardant 360 CDx liquid biopsy testing.

The review has determined that the (Guardant360) provided to the enrollee on March 9, 2020. was not medically reasonable or 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 services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (Guardant360) provided to the enrollee on March 9, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (80324, 80345, 80353, 83992, 80361, 80335,
80346, 80356, 80354, 80329) provided on April 22, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not
payable.

The Plan must follow Medicare rules. Medicare rules say that a status indicator of "I" under the Physician Fee
Schedule indicates that the code in question is not valid for Medicare purposes.

We looked at the file and Medicare rules. Codes 80324, 80345, 80353, 83992, 80361, 80335, 80346, 80356,
80354, and 80329, are assigned a status indicator of "I" under the Physician Fee Schedule, which means that
these codes are not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for,
these services. Based on this information, we decided that Medicare rules for coverage of the services have not
been met. Therefore, we decided that the Plan does not have to pay for the services (80324, 80345, 80353,
83992, 80361, 80335, 80346, 80356, 80354, 80329) provided on April 22, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the inpatient hospital care provided from 
January 21, 2021, to February 2, 2021.  
You asked the Plan to waive the copay for the inpatient services. You say that you cannot afford the charges. 
The Plan denied your request. The Plan says the copay was applied correctly.  
The rules say that a Cost plan must disclose in writing all benefits available under the Plan. The health plan 
contract says that enrollees must pay a $200 copay for inpatient hospital care.  
You have been asked to pay a $200 copay for the inpatient services. The services fall 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 copay for the inpatient hospital care 
provided from January 21, 2021, to February 2, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services provided to the enrollee on October 23,
2020.

You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says Medicare billing criteria were not met. The Qualified Independent Contractor (QIC) overturned the Plans denial. The Plan requested a reopen and stated that the QIC did not apply the correct billing criteria.

Our Medical Director looked at the case file and the reopen request. At issue is whether procedure code 26125-
F3 is supported by the medical documentation. The QIC reviewer determined that the code is supported.
The reviewer found that the operative report documents a fasciotomy was performed and tendon sheaths freed
on the left ring finger, therefore CPT 26125 is confirmed. The Plan requested a reopen and argues that there is
no documentation in the operative report of release of F3 proximal interphalangeal joint (PIP) contracture or
release. "The narrative documents release of the F3 metacarpophalangeal joint (MP) joint only, for which there
is a more appropriate CPT code that describes the procedure."

The medial records stated that the enrollee had Dupuytren's contractures of the left index, middle, and ring
fingers. The operative note documents the following: "Attention was then turned to the ring finger. The patient
has a peritendinous cord causing a 35-degree ring finger metacarpophalangeal joint flexion contracture. A
longitudinal incision was made centered on the cord. A transverse incision was then made in the distal palmar
crease to facilitate exposure. In the proximal portion of the exposure, the fascia was amputated. The common
neurovascular bundles to the third and fourth web spaces were identified and protected. Using skin hooks, a
distally based flap of skin was elevated in order to remove the distal portion of the cord and eliminate the ring
finger flexion contracture".

Our Medical Director has concluded that the Plan is correct in this case. This procedure describes
metacarpophalangeal joint release, and not interphalangeal joint. Therefore, this procedure would not be
covered.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pay for surgical services provided to the enrollee on October 23, 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 an LTACH is medically necessary. The Plan denied your request. The Plan says the criteria for admission to an LTACH 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 a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where they are 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay from January 29
through February 6, 2021.

You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you disagree with
being charged these copayments. The Plan denied your request. The Plan says the correct cost share applied to
the claim.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a
copayment of $625 per day for days 1 to 3 and a $0 copayment per day, days 4 to 90
for Inpatient Hospital Care.

You have been asked to pay a copayment $1,875 ($625 per day for days 1 to 3 and a $0 copayment per day,
days 4 to 90) for the inpatient hospital stay. The 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 the inpatient hospital stay from
January 29 through February 6, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab and radiology services provided February 18, 2021 to February 28, 2021.

You asked the Plan to waive the copayment for the lab and radiology services. You say that the copayments should be waived. The Plan denied your request. The Plan says the correct cost-sharing was 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 $35 and $110 copayment for lab and radiology services.

You have been asked to pay a $35 and $110 copayment for the lab and radiology services. 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 lab and radiology services provided February 18, 2021 to February 28, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a Computed Tomography (CT) scan provided (71250) provided April 1, 2021.
You asked the Plan to waive the copayment for the CT scan. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct copayment was 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 $295 copayment for high technology imaging. You have been asked to pay the allowable amount of $167.70 for the CT scan. The CT scan falls within the high technology imaging benefit category. The allowable amount of $167.70 is less than the $295 copayment
listed in the Evidence of Coverage. 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 Computed Tomography (CT) scan provided (71250) provided April 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a right knee brace (L1833) with suspension sleeve (L2397) provided on September 2, 2020.

You asked the Plan to pay for a knee brace with suspension sleeve. You say that the requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met because the requested items are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for a knee brace with suspension sleeve. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found that there is no documentation of a recent injury to, or recent surgical procedure on, the enrollee's knee, and there is insufficient credible objective documentation of joint laxity. The item coded L2397 (sleeve) is not separately payable when the base item is not covered. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a knee brace with suspension sleeve have not been met. Therefore, we decided that the Plan does not have to pay for a right knee brace (L1833) with suspension sleeve (L2397) provided on September 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an orthosis (L0650) provided to the enrollee on July 13, 2020.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the provider is known for utilizing a telephonic consult to obtain the clinical information for durable medical equipment.

The Plan must follow Medicare rules. Medicare rules say that Medicare rules say that durable medical equipment generally must be ordered by a physician who has furnished a consultation or treats an enrollee for a specific medical problem.

The file does not contain documentation of an established relationship between the enrollee and the ordering provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this testing have not been met. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for an orthosis (L0650) provided to the enrollee on July 13, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for long term acute care hospital (LTACH) services.

You asked the Plan to pay for the LTACH services. You say that LTACH admission is medically necessary. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care and does not require transfer to a LTACH.

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 pay for 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 in this case the enrollee was admitted following ventricular fibrillation cardiac arrest. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that she is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pay for long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit (99213) provided April 28, 2021.

You asked the Plan to waive the copayment for the office visit. You say that the services were over priced and the copay should be waived. The Plan denied your request. The Plan says the correct cost-sharing was 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 $5 copayment for primary care visits. 

You have been asked to pay a $5 copayment for the office visit. The office visit falls within the primary care visits 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 office visit (99213) provided April 28, 2021.