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

We decided that the Plan does not have to waive the copayment for the emergency care you had on June 23, 2020.
You asked the Plan to waive the copayment. The Plan denied your request. The Plan says you are responsible for the copayment.
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 $50 copayment for emergency care. Review of the file shows that you were provided emergency care on June 23, 2020. You have been asked to pay a $50 copayment for the services. The services falls within the emergency 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 emergency care you had on June 23, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health care services provided from March 4, 2020, to March 17, 2020.
You asked the Plan to pay for the home health care services. You say that withholding payment for services rendered to enrollees under commercial plans to recoup Medicare Advantage payments is without justification and violates the law. The Plan denied your request. The Plan says the services were rendered by a provider who does not participate with Medicare.
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. The services were rendered by a provider who is not eligible to provide services under Original Medicare. Based on this information, we decided that Medicare rules for coverage of the home health care services have not been met. Therefore, we decided that the Plan does not have to pay for the home health care services provided from March 4, 2020, to March 17, 2020.
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-approve the LTACH services. You say that the complexity of the enrollee's medical status can safely be managed at the LTACH. The Plan denied your request. The Plan says criteria for admission to the 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 the enrollee does not require services at the LTACH that are not already available and covered at the current facility. Our reviewer found that there are no services at the LTACH that the patient requires that are not already available and covered at the current facility. Our physician reviewer also found that this request for LTACH services will be considered not medically necessary at this time. Transfer to a lower level of care may be considered when treatment has completed and the enrollee is more stable.

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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a refraction (92015) provided on November 24, 2020.
You asked the Plan to pay for a refraction. You say that you needed this due to vision problems. The Plan denied your request. The Plan says this is not covered in this circumstance.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers eye refractions during a routine exam performed by an in-network Provider. We looked at the file and the Plan's rules. The records show that the refraction at issue was not performed by an in-network Provider. Based on this information, we decided that the Plan's rules for coverage of a refraction have not been met. Therefore, we decided that the Plan does not have to pay for a refraction (92015) provided on November 24, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the medical services provided after hours (99050) and the drainage of a skin abscess (10060) provided on November 18, 2019 and November 26, 2019.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that the services are not payable as the primary insurance will need to first process the claim for payment.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. The Plan has not met its obligation in regard to coordination of benefits. Specifically, the Plan has contacted you for information to process the claims; however, this is not sufficient. The Plan is responsible to coordinate benefits with primary insurers by sending the bill directly to the primary insurer for payment, or by directing the provider to send the bill to the primary insurer, or the Plan may pay for the services and submit a bill to the primary insurer for reimbursement. Therefore, we decided that the Plan has to pay for the medical services provided after hours (99050) and the drainage of a skin abscess (10060) provided on November 18, 2019 and November 26, 2019.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on November 11,
2020.
You asked the Plan to waive the copayment for a specialist visit. You say that this was a follow-up visit and
you disagree with the copayment. The Plan denied your request. The Plan says the claims were processed
correctly, and you are being charged the correct 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 $50
copayment for each specialist visit.
You received a specialist visit on November 11, 2020. Follow-up visits are subject to cost-sharing charges.
Therefore, you are responsible to pay the $50 copayment.
You have been asked to pay a $50 copayment for a specialist visit. A specialist 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 a specialist visit provided on November 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for glucose monitoring supplies (K0553) provided on October
21, 2020.
You asked the Plan to pay for glucose monitoring supplies. You say that the criteria for coverage have been
met. The Plan denied your request. The Plan says this is not supported by the records.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a
physician order and proof of delivery.
The record does not contain a valid proof of delivery for the supplies provided in this case. The proof of
delivery in the file shows a shipping date of October 16, 2020, and a delivery date of October 19, 2020. Neither
date matches the billed date of service. Therefore, we decided that the Plan does not have to pay for glucose
monitoring supplies (K0553) provided on October 21, 2020.
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 this is the best level of care. The Plan denied your request. The Plan says that you would be safely and equally well served with skilled therapy services at an alternative level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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. The complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for COPD and pseudomonas pneumonia. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve TheraSkin wound application (15275).
You asked the Plan to pre-approve TheraSkin wound application. You say that the wound care is necessary for the enrollee. The Plan denied your request. The Plan says there is no applicable CMS guidance for the provider and enrollee's geography. The clinical value and effectiveness of TheraSkin Wound Application in the setting of leg ulcers have not been demonstrated in the peer-reviewed literature. Therefore, the denial was appropriate.
The Plan must follow Medicare rules. Medicare rules say that the plan will generally cover your medical care as long as the care you receive is included in the plan's Medical Benefits Chart. The rules also say that experimental and investigational devices are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of TheraSkin wound application have not been met. Therefore, we decided that the Plan does not have to pre-approve TheraSkin wound application (15275).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on January 7,
2021.
You asked the Plan to waive the copayment for a specialist visit. You say that you were inpatient when the
doctor saw you in your room and you disagree with the charges. The Plan denied your request. The Plan says
the claims were processed correctly and you are being charged the correct 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 $40
copayment for each specialist visit.
The record shows that you received a specialist visit during an observation stay on January 7, 2021. Therefore,
you are responsible to pay the $40 copayment. Please note, outpatient hospital charges are in your financial
favor.
You have been asked to pay a $40 copayment for a specialist visit. A specialist 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 a specialist visit provided on January 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove Dexcom Glucose Monitor, a continuous glucose monitor.

You asked the Plan to preapprove the continuous glucose monitor. You say that the CGM is necessary. The Plan denied your request. The Plan says the enrollee does not meet coverage criteria due to not using insulin.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of the continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to preapprove Dexcom Glucose Monitor, a continuous glucose monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive eye examination (92014) scanning
computerized ophthalmic diagnostic imaging (92134) extended ophthalmoscopy (92202) and intravitreal
injection (67028) provided July 22, 2020.
You asked the Plan to pay for the vision services. You say that you missed getting the authorization, but the
procedure performed was medically necessary as mentioned in the medical records. The Plan denied your
request. The Plan says enrollee's must receive their medical services from an in-network provider with the
exception being urgent or emergent services. Non-emergent services with non-contracted providers require
prior authorization before services being rendered.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan covers these services when rendered by an in-network provider.
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for
coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pay for
the comprehensive eye examination (92014) scanning computerized ophthalmic diagnostic imaging (92134)
extended ophthalmoscopy (92202) and intravitreal injection (67028) provided July 22, 2020.
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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. 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 patient was admitted for infection of a penile prosthetic and pneumonia. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care. 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 for the enrollee.
Appeal type: Outpatient Therapies
Decision: Partially Favorable

We decided that the Plan has to pre-approve an additional two (2) PT visits. We decided that the Plan does not
have to pre-approve an additional eight (8) PT visits.
You asked the Plan to pre-approve an additional ten (10) PT visits. The Plan says that an additional ten (10) PT
visits are not medically necessary.
We decided that the Plan has to pre-approve two (2) additional PT visits.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.
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 additional PT visits. Our reviewer says
that an additional two (2) PT visits are medically necessary. Our physician reviewer found that two (2)
additional physical therapy visits to transition to a home exercise program appears appropriate at this point and
is approved. Therefore, we decided that the Plan has to pre-approve two (2) additional PT visits.
We also decided that the Plan does not have to pre-approve eight (8) additional PT visits.
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 additional PT visits. Our reviewer says
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's
condition. Our physician reviewer found based on the medical records provided there is no documentation that
the requested therapy is generally accepted as specific and effective therapy for the enrollee's condition. Based
on the available records the enrollee appears to have improved over the course of the 22 physical therapy
sessions to the point of being able to manage basic activities of daily living though some mild pain persists.
Eight (8) additional skilled therapy sessions at this point does not appear to be likely to achieve any significant
improvement in the enrollee's symptoms or functional status. There is no documentation that the unique skills
of a professional therapist are required to safely and effectively provide treatment, that the services can be
safely and effectively performed only by a therapist or under the supervision of a therapist. There is no
documentation that the specialized skill, knowledge and judgment of a qualified therapist is required to
establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow
further deterioration. Therefore, we decided that the Plan does not have to pre-approve eight (8) additional PT
visits.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for a Players Club pass provided on February 4, 2021.
You asked the Plan to reimburse you for the Players Club pass. The Plan denied your request. The Plan says
Players Club is not a covered benefit.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
The Plan's rules for coverage of gym benefits have not been met because Players Club is not covered under
your fitness benefit. Therefore, we decided that the Plan does not have to reimburse you for a Players Club pass
provided on February 4, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the FoundationOne Heme comprehensive genomic profiling (CGP) test (F1 Heme) provided on November 12, 2020.
You asked the Plan to pay for the FoundationOne Heme CGP test. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as 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 the denied CPT code is not supported in the medical record. Specifically, the testing at issue in this case should be reported with CPT code 81479. Based on this information, we decided that Medicare rules for coverage of the FoundationOne Heme CGP test have not been met. Therefore, we decided that the Plan does not have to pay for the FoundationOne Heme comprehensive genomic profiling (CGP) test (F1 Heme) provided on November 12, 2020.