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

We decided that the Plan does not have to pay for physician services provided on August 8, 2019 by the out of network provider.
You asked the Plan to pay for physician services. You say that you would like this claim to be reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the member's primary physician did not refer the enrollee for these 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 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 physician services provided on August 8, 2019 by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug injection and does
not have to waive the copayment for the administration provided by the physician on August 26, 2019.
You asked the Plan to waive the coinsurance for a Medicare Part B drug injection and to waive the copayment
for the administration. You say that you thought that you would only owe a $50 copayment and 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 20%
coinsurance for Medicare Part B drugs. Your contract with the Plan also clearly says that you must pay a $10
copayment for primary care provider services.
You received a Medicare Part B drug on August 26, 2019. The allowed amount is $1,121.40 and 20% of that is
$224.28.
You received the administration of a Medicare Part B drug on August 26, 2019. Therefore, you are responsible
to pay the $10 copayment.
The total amount you owe is: $234.28.
You have been asked to pay the total amount of $234.28 for a Medicare Part B drug injection and the
administration. A Medicare Part B drug injection falls within the Medicare Part B prescription drugs benefit
category. The administration 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 coinsurance for a Medicare Part B drug
injection and does not have to waive the copayment for the administration provided by the physician on
August 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ultrasonic osteogenesis stimulator for the enrollee.
You asked the Plan to pre-approve this item. You say that this device has been shown to significantly accelerate healing time and can reduce the incidence of a non-union in a high risk patient. The Plan denied your request. The Plan says that the enrollee does not meet criteria as his injury is 57 days from the date of injury.
The Plan must follow Medicare rules. The rules say that an ultrasonic osteogenesis stimulator is covered for nonunion of fracture documented by a minimum of two sets of radiographs obtained prior to starting treatment with the osteogenesis stimulator, separated by a minimum of 90 days. In this case, nonunion of fracture is not considered to exist under Medicare rules. The file does not show that there were 2 or more serial radiographs separated by 90 or more days confirming that healing had ceased. Therefore, we decided that the Plan does not have to pre-approve an ultrasonic osteogenesis stimulator for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the denosumab injection provided on July 25, 2019 by an out of network provider.
You asked the Plan to pay for the denosumab injection. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.
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 the denosumab injection provided on July 25, 2019 by the out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient mental health care provided from July 12, 2019 through July 16, 2019.
You asked the Plan to pay for inpatient mental health care. You say that the stay was medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient mental health care. Our physician reviewer found based upon review the records provided it was not expected this enrollee would improve in a reasonable period of time as she did not have dangerousness to self or others, auditory or visual hallucinations and was not showing any withdrawal symptoms. She was cooperative and compliant with treatment. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care as she did not have dangerousness to self or others. The health plan's denial of inpatient psychiatric services appears appropriate. This enrollee did not appear to require inpatient mental health treatment as she was not a danger to herself or others and was cooperative with care without any aggressive behaviors. It did not appear that active treatment was taking place. It did not appear that the services were reasonably expected to improve the patient's condition or for the purpose of diagnosis. This patient was treated under an individualized treatment found in the record. It did appear that the records were supervised and evaluated by a physician. Based upon review the records provided for the admission of this patient does not meet criteria for acute inpatient mental health treatment as she was not shown to be a danger to herself or others, auditory or visual hallucinations. She is noted to be cooperative and compliant with treatment while not showing any withdrawal symptoms. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient mental health care have not been met. Therefore, we decided that the Plan does not have to pay for inpatient mental health care provided from July 12, 2019 through July 16, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Part B injection provided on September 17, 2019.You asked the Plan to waive the coinsurance forthe Part B injection. You say that you are appealing because you thought this service should be covered. 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 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay $47.42 which is 20% of the allowed amount for the Part B injection. The allowed amount is $237.08. ($237.08 x 20% = $47.42). The Part B injection falls within the "Medicare Part B prescription drugs" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing isa 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 forthe Part B injection provided on September 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on February 11, 2019 by the out of 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 an out-of-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 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 the medical services provided on February 11, 2019 by the out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forknee orthosis (L1833) provided to the enrollee on September 25, 2019, by an out-of-network provider.You asked the Plan to pay forthe orthosis. You say that the durable medical equipment is medically necessary.The Plan denied your request. The Plan says they did not authorize any services. The Plan states 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 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 forknee orthosis (L1833) provided to the enrollee on September 25, 2019, by an out-of-network provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator.
You asked the Plan to pre-approve a portable oxygen concentrator. You say that you need this to be able to attend outside activities. The Plan denied your request. The Plan says the oxygen equipment is only for use inside the home.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from May 29, 2018 through June 1, 2018.You asked the Plan to pay foracute inpatient hospital care. You say that the stay was medically necessary.The Plan denied your request. The Plan says the stay is not medically necessary.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 applythe relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the enrollee did not require an inpatient level of care after May 28, 2019.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 pay forthe acute inpatient hospital care provided from May 29, 2018 through June 1, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care (99310), prolonged service in the inpatient or observation setting (99356), and the medication list documented in the medical records (1159F) provided on June 3, 2019 by out of network provider.You asked the Plan to pay forsubsequent nursing facility care, prolonged service in the inpatient or observation setting, and the medication list documented in the medical records. You say you are merely asking the plan to approve the services and reprocess the claim for payment.The Plan denied your request. The Plan says the member sought non-emergent/non-urgent services on his own with a non-contracting provider and did not allow the primary care physician (PCP) to request approval from the Health Plan which would have advised him where to go for the 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 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 forsubsequent nursing facility care (99310), prolonged service in the inpatient or observation setting (99356), and the medication list documented in the medical records (1159F) provided on June 3, 2019 by out of network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services.You asked the Plan to pre-approveSNF services. You say that the enrollee needs to gain more strength to be able to go back to her own life.The Plan denied your request. The Plan says the enrollee does not require skilled nursing 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 SNF services. Our physician reviewer found that the enrollee's current level of function is ambulating 400 feet using a rolling walker with contact guard assist, independent with bed mobility, contact guard assist with sit to stand, and supervision withbalance. No recent occupational therapy notes were available for review. There are no noted daily skilled complex nursing needs. She is ambulating household distances and requires little assistance with mobility and transfers. While she may benefit from continuing physical and occupational therapy, the records do not support the need for daily therapy.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from September 25, 2018 through September 26, 2018.You asked the Plan to pay foracute inpatient hospital care. You say that the stay was medically necessary.The Plan denied your request. The Plan says the stay is not medically necessary.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 pay for acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the record does not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (ED) and/or observation care) would span two midnights.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 pay forthe acute inpatient hospital care provided from September 25, 2018through September 26, 2018
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe periodontal maintenance (D4910) provided on May 8, 2019.You asked the Plan to pay forthe dental service. You say that you received 2 annual cleanings from the dentist. You say that your general dentist is aware of your preventive cleanings, including prophylaxis are provided by this dental practice.The Plan denied your request. The Plan says periodontal maintenance is not a covered service. The Plan also says that periodontal maintenance is not a preventive dental service.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, periodontal maintenance is not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe periodontal maintenance (D4910) provided on May 8, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One.You asked the Plan to pre-approve Synvisc-One. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested drug is not medically necessary.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 Synvisc-One. Our reviewer says thatthe documentation does not support that the requested drug is medically reasonable or necessary. Our physician reviewer found you have knee pain and a diagnosis of left knee osteoarthritis. This is confirmed by x-rays. You have failed conservative treatment. The documentation does not support that you have tried and failed the required drugs, Orthovisc and Monovisc. The documentation does not indicate that the required drugs would likely be less effective and/or likely have adverse effects. Therefore, you do not meet criteria for the requested drug.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc-One have not been met.Therefore, we decided that the Plandoes not have to pre-approveSynvisc-One.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Magnetic Resonance Angiography (MRA) of the Head and Neck (70549, 70544).
You asked the Plan to pre-approve the MRA. You say that the MRA is medically necessary. The Plan denied your request. The Plan says the same procedure was already performed with negative results, a repeat scan is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the MRA. Our reviewer says that the requested MRA is not medically necessary. Our physician reviewer found the condition the enrollee suffers from is not likely to be treated with surgical intervention. The patient had previously undergone MRA of the head and neck prior to the ordering of the requested procedures. The previously completed studies had normal results. A repeat procedure is not 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 the MRA have not been met. Therefore, we decided that the Plan does not have to pre-approve Magnetic Resonance Angiography (MRA) of the Head and Neck (70549, 70544).