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

We decided that the Plan does not have to waive the copayment for SNF care from May 14, 2019 through May 21, 2019.
You asked the Plan to waive the copayment for SNF care. You say that the member is on a fixed income and are questioning the health plan wanting the member to pay for rehab that was recommended by the professionals at the hospital. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that the enrollee received SNF care from May 14, 2019 through May 21, 2019. The member had another two SNF claims in the history for the date of service March 14, 2019 through March 31, 2019  and date of service April 1, 2019 through April 7, 2019 under the facility. In addition, there is an inpatient hospital claim on file for dates of service May 3, 2019 through May 14, 2019. Services from May 14, 2019 through May 21, 2019 began the 25th day in SNF. Per the EOC, seven (7) day admission charges with $142.00 per day, left the member responsible for a cost share of $994.00 (7 x $142.00 = $994.00). Based on these findings, the member was found responsible for the total amount of $994.00. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for SNF care from May 14, 2019 through May 21, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the CT scan provided on November 18, 2019.
You asked the Plan to reduce the copayment for the CT scan. You say that you did not realize there was a $325 copayment. You say you should have gone the emergency room instead and paid $90. 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 $325 copayment per day for Medicare-covered diagnostic radiology services. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $325 copayment for the CT scan.
You have been asked to pay a $244.65 copayment for the CT scan. The CT scan falls within the "Outpatient diagnostic tests and therapeutic services and supplies" 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 reduce the copayment for the CT scan provided on November 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation, removal of residual tooth roots, and panoramic x-ray provided on September 20, 2019.
You asked the Plan to pay for the problem focused limited oral evaluation, removal of residual tooth roots, and panoramic x-ray. You say that your tooth had to be extracted due to pain and cutting into your jaw. The Plan denied your request. The Plan says these services are not covered according to your plan benefits.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation, removal of residual tooth roots, and panoramic x-ray provided on September 20, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Darbepoetin alfa for the enrollee.
You asked the Plan to pre-approve the requested drug. The Plan denied your request. The Plan says the drug is not medically necessary for the enrollee's condition.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 requested drug. Our physician reviewer found that the enrollee has myelodysplastic syndrome and anemia. The documentation does not support that the requested drug is medically reasonable and necessary due to the pre-treatment serum erythropoietin level greater than 500 milliunits per milliliter. There is also a reported diagnosis of chronic kidney disease, but the provided records do not document this, and there are no laboratory tests of renal function included in the records. Based on the provided medical records, the documentation does not support that the requested drug is safe and effective for the enrollee. 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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Darbepoetin alfa for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that you would like the SNF stay to continue as the SNF is the safest option for the enrollee. The Plan denied your request. The Plan says daily skilled nursing or therapy services are not needed.
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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is medically stable, and no skilled nursing needs are identified. The enrollee does not require daily therapy services, and often refuses them. The enrollee does not meet criteria for SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: ER
Decision: Favorable

We decided that the Plan has to waive the copayment for an observation stay provided on May 10, 2018.
You asked the Plan to waive the copayment for an observation stay. You say that you disagree with the charges. The Plan denied your request. The Plan says that 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. Your contract with the Plan says that enrollees must pay a $0 copayment for outpatient surgery. The Plan says you must pay $206.30 for an observation stay. Based on the Plan contract, however, you cannot be asked to pay more than a $0 copayment for an observation stay. Therefore, we decided that the Plan has to waive the copayment for an observation stay provided on May 10, 2018.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that the records provided support the need for
care in a SNF. The Plan denied your request. The Plan says the enrollee has no daily skilled therapy or daily
skilled nursing needs.
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 SNF services. Our reviewer says
that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral
medications and had stable vital signs. The enrollee received physical therapy and occupational therapy
evaluations only. By the dates in question, the enrollee was at a modified independent to stand by assist level
with functional mobility, including gait. The enrollee required varying assist with activities of daily living. The
enrollee was felt to be at his baseline functional status. There are no identifiable skilled nursing service needs.
There are no identifiable skilled therapy service needs. The enrollee does not meet the severity of illness or
intensity of service criteria for an inpatient basis in a skilled nursing facility setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the SNF services have not been met. Therefore, we decided that the Plan does
not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lumbar-sacral orthosis provided on November 18, 2019.You asked the Plan to pay forthe lumbar-sacral orthosis (L0648). You say that the Plan should pay this claim.The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order, itemized invoice or proof of delivery.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 shows that the Plan made several attempts to obtain the physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid physician order and proof of delivery for the supplies provided in this case.Therefore, we decided that the Plan does not have to pay forthe lumbar-sacral orthosis provided on November 18, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from August 5, 2019 through August 9, 2019.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file shows that you were admitted on August 5, 2019 and discharged on August 9, 2019. You were asked to pay a $350 copayment per day from August 5, 2019 through August 8, 2019, days 1-5 of your inpatient hospital care. You were discharged on August 9, 2019 and there was no copayment charge for the day of discharge. Per your contract there is a $350 copayment per day required for days 1-5 for in-network inpatient hospital care. 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 inpatient hospital care from August 5, 2019 through August 9, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approveCardioMEMSHF System for the enrollee. You asked the Plan to pre-approvethese 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. 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 NYSHA Class III congestive heart failure with preserved ejection fraction requiring hospitalization. In this circumstance therapy change based on data obtained from a CardioMEMSdevice has been demonstrated in only one trial to help reduce hospital readmission compared to standard medical therapy. The services are considered experimental/investigational at this time and not medically necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pre-approveCardioMEMS HF System for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to approveadditional payment for the vision services provided on January 8, 2020.You asked the Plan to approveadditional payment for the vision services. You say that this should be covered because you were told you could use your benefits.The Plan denied your request. The Plan says that they have paid up to the allowed amount.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 health plan contract says that they cover up to $75 per calendar year for a routine vision exam and up to $220 per calendar year for a combination of routine prescription contacts, routine prescription lenses, routine vision frames, and/or upgrades, such as tinting.We looked at the file and the Plan's rules. The file shows that the plan has approved the maximum yearlybenefit for the requested services. There is no provision in the contract which would require the plan to approve more than this amount.Therefore, we decided that the Plan does not have to approveadditional payment for the vision services provided on January 8, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forcataract surgeries provided on June 7, 2019 and July 26, 2019.You asked the Plan to waive the copayments forcataract surgeries. You say that you disagree with the denial of charges.The Plan denied your request. The Plansays 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 $0 copayment for any surgical procedure provided during a screening colonoscopy and a $375 copayment for all other ambulatory surgical center services.You received cataract surgeries on June 7, 2019 and July 26, 2019. Therefore, you are responsible to pay a $375 per each service. The total amount you owe is: $750.  You have been asked to pay the total copayment amount of $750 for cataract surgeries. Cataract surgeries fall 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 copayments forcataract surgeries provided on June 7, 2019 and July 26, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided by the Laboratories on April 30, 2019.
You asked the Plan to pay for drug tests. You say that you have submitted a valid physician laboratory requisition form. The Plan denied your request. The Plan says the denial of payment for this service is correct, because the documentation submitted does not include a valid physician order, lab requisition, or medical records for the test billed.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a valid physician order or clear intent to order the specific test billed on this claim. Based on this information, we decided that Medicare rules for coverage of drug tests have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided by the Laboratories on April 30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) for the enrollee.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that a therapeutic CGM is covered when specific criteria are met. 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 enrollee does not meet the criteria for coverage. Our physician reviewer found the enrollee has type II diabetes and is not insulin-treated. The records do not support that he meets the criteria for coverage of the requested CGM and the services are 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 Freestyle Libre continuous glucose monitor (CGM) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services for the enrollee.You asked the Plan to pre-approveIRF care. You say that the enrollee is only able to walk a short distanceThe Plan denied your request. The Plan says the enrollee does not need an intensive team approach to care, or need to be seen by a rehab physician three times a week.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 physician reviewer found that the enrollee's current level of function is supervision for ambulation using a rolling walker, modest progress with mobility, moderate assist for bed mobility, and contact guard assist for toilet transfers. 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 his medical status requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional physical and occupational therapy, but 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-approveacute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomography (CT) of the abdomen/pelvis and of the soft tissues of the neck.
You asked the Plan to pre-approve the CT scans. You say that the records provided support the medical necessity of the requested CT scan services. The Plan denied your request. The Plan says the requested CT scan services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 CT scans. Our physician reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee has a history of diffuse large b-cell lymphoma (DLBCL) and completed therapy in September of 2018. Our physician reviewer found that the enrollee had a PET/CT in January of 2019 which was negative for malignancy. Our physician reviewer found that the enrollee had a PET/CT in June of 2019 which was stable and without change. Our physician reviewer found that the enrollee had a CT of the chest in November of 2019 which was stable. Our physician reviewer found that there is no clinical indication for the CT scans that are now being requested. 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 CT scans have not been met. Therefore, we decided that the Plan does not have to pre-approve computed tomography (CT) of the abdomen/pelvis and of the soft tissues of the neck.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network radiation oncologist.
You asked the Plan to pre-approve these services. You say that your care can only be given at a tertiary center. The Plan denied your request. The Plan says the services are available from network providers.
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 tertiary 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 a referral to an out-of-network radiation oncologist.