Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on November 4, 2019.
You asked the Plan to waive the copayment for the specialist office visit. You say that you sent a copy of your bill for review. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 copayment for each visit to a specialty physician office. You have been asked to pay a $35 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office 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 the specialist office visit provided on November 4, 2019.
Your complaint about the provider refusing to give your test results over the phone is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
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 services are not medically necessary. Our physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH) for a subdural hematoma. The enrollee was intubated/ventilated upon presentation and underwent several neurologic surgeries. Additionally, the enrollee received a tracheotomy and feeding tube. The enrollee has been weaned off the ventilator to a tracheotomy collar, but continues to have significant neurologic deficits. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. 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 for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on July 29, 2019.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says the enrollee 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 laboratory services. 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 laboratory services provided on July 29, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for cataract surgery provided on September 30, 2019 and October 21, 2019.
You asked the Plan to waive the copayment for cataract surgery. You say that you are on a fixed income. You say that you have extra supplemental coverage and wonder why you are being charged a copayment. The Plan denied your request. The Plan says the copayments 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 $200 for each Medicare-covered in-network ambulatory surgical center visit or outpatient hospital facility visit. You have been asked to pay $200 for each cataract surgery. The total amount you owe is $400 ($200/surgery x 2 surgeries = $400). 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 for cataract surgery provided on September 30, 2019 and October 21, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total disc arthroplasty for the enrollee.
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan
denied your request. The Plan says the services 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 pre-approve these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee has neck and left upper
extremity pain. Two-level cervical disc replacement remains experimental in nature. More research is needed to
show its safety and efficacy. The procedure is therefore not reasonable or medically necessary at this time.
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 a total disc arthroplasty.
The Plan references Local Coverage Determination (LCD) L35008 in their determination; however, this LCD
does not provide coverage for the services at issue and was not used in the MAXIMUS determination.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the cataract surgery.You asked the Plan to pre-approve the cataract surgery. The Plan denied your request. The Plan says there are doctorsin-network who can perform the same services.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 pre-approved care.The requested provider in this case is nota 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 services. Therefore, we decided that the Plan does not have to pre-approvethe requested cataract surgery.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for psychotherapy provided on October 3, 2019.
You asked the Plan to waive the copayment for psychotherapy. You say that you see your specialist at a mental health clinic. You say that you should only pay $20 to see the specialist. 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 $70 copayment for outpatient mental health care at an in-network outpatient hospital. You have been asked to pay a $70 copayment for psychotherapy. Psychotherapy falls within the "Outpatient mental health care" benefit category. The records show that the psychotherapy was billed by the hospital. 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 psychotherapy provided on October 3, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve continued services. You say that you don't want the enrollee to relapse. The Plan denied your request. The Plan says the enrollee is covered for up to 100 days each benefit period.
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. The file shows that the enrollee received 100 days of SNF care during the benefit period from September 20, 2019 to February 15, 2020. The Plan has covered 100 days of SNF care. Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. the enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foran office visit (99214), an injection beneath the skin or into muscle for therapy, diagnosis, or prevention (96372), and an injection of ibetamethasone acetate and betamethasone sodium phosphate (J0702) provided on September 7, 2019 by out of network provider,"the doctor".You asked the Plan to pay foran office visit and injections. You say that you are appealing the claim payment denial for services rendered to the Plan's member on date of service September 7, 2019.The notes included with the appeal support the need for services.The Plan denied your request. The Plan says the attending provider "the doctor" is a non-participating provider. "the physician assistant" is also a non-participating provider. The plan did not authorize any services. The services are not considered urgent/emergent in nature.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Planhas 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 has network providers available who can provide 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 foran office visit (99214), an injection beneath the skin or into muscle for therapy, diagnosis, or prevention (96372), and an injection of ibetamethasone acetate and betamethasone sodium phosphate (J0702) provided on September 7, 2019 by out of networkprovider,"the doctor".
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approvecontinued skilled nursing facility (SNF) care beyond January 17, 2020 until termination with the Plan.You asked the Plan to pre-approve the continued SNF care. You say that the enrollee continued with the Plan until the end of February and it is felt he continued to require SNF care.The Plan denied your request. The Plan says that the enrollee is no longer with the plan so the Plan does not have to cover continued care.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 pre-approve the continued SNF care. Our reviewer says that the documentation provided is not sufficient to determine whether daily skilled care was need beyond the denial date. Our physician reviewer found He was admitted for SNF level care after discharge on 12/07/2019. Case notes indicate that SNF level care was approved through 01/17/2020. There was no clinical information provided after the date of admission.The member continued to requireoversight of his medical conditions and medication management with skilled nursing services. The need for continued skilled therapy is not known. The reason he was discharged from therapy was not provided. Whether his condition would be expected to deteriorate with services provided on a less than daily basis cannot be 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 continued SNF care have been met. The Plan must continue coverage for the SNF skilled services until such time as the enrollee no longer has coverage with the Plan.Therefore, we decided that the Plan has to pre-approvecontinued skilled nursing facility (SNF) care beyond January 17, 2020 until termination with the Plan.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for oncology (prostate) gene expression profile testing provided on September 26, 2019.
You asked the Plan to pay for genetic test. You say that this testing was ordered by the enrollee's treating physician because it was medically necessary. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this test is not medically necessary and not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that oncology (prostate) gene expression profile testing with procedure code 0005U was not covered by Medicare for date of service September 26, 2019. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of genetic test have not been met. Therefore, we decided that the Plan does not have to pay for oncology (prostate) gene expression profile testing provided on September 26, 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 the enrollee's rehab would be provided best in the IRF setting.The Plan denied your request. The Plan says there is no need for an intensive rehab program and she has not acute medical issues.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 this 78 year-old female was admitted to the acute care hospital secondary to a T12 acute compression fracture requiring kyphoplasty on 1-29-20. She had a lumbar fusion on 11/13/19. She is noted to be medically stable at this time. She was fitted with a back brace and treated for a UTI. Currently, the patient was able to walk 40' with a walker with minimal assistance, transfers and bed mobility required minimum Stand By Assist (SBA), upper body Activities of Daily Living (ADL) required maximal assistance to don the thoracic back brace and lower body self-care skills require total assistance. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the patient's functional status requires the intensity of an IRF stay with close physician or nursing supervision. The patient may benefit and participate in additional therapy of PT and OT but the patient does not require this on an intensive rehabilitation facility therapy program level in an IRF.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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the skin surgery provided on August 7, 2019.

You asked the Plan to waive the coinsurance for the skin surgery. You say that you do not understand why you are receiving this bill. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 25% coinsurance for each covered surgery or observation room service in an outpatient hospital. 

You have been asked to pay $845.42 which is 25% of the allowed amount for the skin surgery. The allowed amount is $3,381.69. ($3,381.69 x 25% = $845.42). The skin 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 coinsurance for the skin surgery provided on August 7, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (80307, G0482) provided on December 13, 2018
by the out of network provider.
You asked the Plan to pay for drug testing. You say that you were not aware of the requirement of obtaining a
prior authorization. You conducted the test ordered by the referring physician in good faith, identified the
service to be medically necessary and that you are a licensed and approved independent laboratory. The Plan
denied your request. The Plan says members must receive their care from a network provider. The care
received from an out-of-network provider will not be covered. The only exceptions are emergency care or
urgently needed services that are received from an out-of-network provider. An authorization is required prior
to seeking care from an out-of-network provider.
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 has network providers
available who can provide 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 drug testing (80307, G0482) provided on
December 13, 2018 by the out of network provider.
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. The Plan denied your request. The Plan says IRF admission is not medically necessary.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 that the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the enrollee's medical status requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional therapy of physical therapy and occupational therapy, but the enrollee does not require this therapy or appear to tolerate this therapy on an intensive rehabilitation facility therapy program level in an IRF.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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a Midazolam Hydrochloride injections (J2250) and Fentanyl injections (J3010) provided on February 5, 2019.
You asked the Plan to pay for the injections. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the items billed are packaged into other services and no separate APC payment is made.
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 codes J2250 and J3010 are not supported in the record. Specifically, per Addendum B, these codes have a status indicator of N. This means that payment is packaged into the payment for other services and there is no separate APC payment. Based on this information, we decided that Medicare rules for coverage of the injections have not been met. Therefore, we decided that the Plan does not have to pay for a Midazolam Hydrochloride injections (J2250) and Fentanyl injections (J3010) provided on February 5, 2019.