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

We decided that the Plan does not have to pay for the domiciliary or rest home visit provided on September 10, 2019 by an OON provider.You asked the Plan to pay for the domiciliary or rest home visit. You say that your provider depends upon the hospital staff to verify eligibility and to obtain the proper authorization for in-network and out-of-network providers from the enrollee's insurance.The Plan denied your request. The Plan says both the rendering provider and rendering facility are non-participating with the enrollee's Plan. The Plan also says that prior authorization was not obtained.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 domiciliary or rest home visit provided on September 10, 2019 by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the CXBladder Detect test provided to the enrollee on September 3, 2019.
You asked the Plan to pay for the test. You say that this test may be ordered on patients at an increased risk of bladder cancer to aid in the diagnosis of new or recurrent bladder cancer. The Plan denied your request. The Plan says the test is considered experimental and investigational.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the test. Our reviewer says that the services at issue in this case were not medically reasonable or necessary. Our physician reviewer found the enrollee has had extensive evaluation for hematuria over a period of several years. There has been no evidence of malignancy, including a cystoscopy in September, 2019, which was without change. 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 test have not been met. Therefore, we decided that the Plan does not have to pay for the CXBladder Detect test provided to the enrollee on September 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on September 14, 2019 to October 12, 2019 by an out of network (OON) provider.You asked the Plan to pay for an office visit. You say that you would like these office visits approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained for these service.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 foran office visit provided on September 14, 2019 to October 12, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair power seat elevation feature
You asked the Plan to pre-approve a power seat elevation feature (E2300). You say that a power seat elevation feature is necessary for the enrollee to transfer to and from the wheelchair and reach during activities of daily living. The Plan denied your request. The Plan says power seat elevation features are not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Medicare rules say options and accessories for wheelchairs are covered if the beneficiary has a wheelchair that meets Medicare coverage criteria and the option/accessory itself is medically necessary. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair power seat elevation feature
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical nutrition therapy services provided to the enrollee on August 29, 2019.
You asked the Plan to pay for medical nutrition therapy services. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services only for enrollees with renal disease or diabetes. The records do not show that the enrollee suffers from renal disease or diabetes. Therefore, we decided that the Plan does not have to pay for the medical nutrition therapy services provided to the enrollee on August 29, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the DME provided to the enrollee on August 12, 2019, by an in-network provider.
You asked the Plan to waive the coinsurance for the DME. You say that you are appealing the member's cost-share responsibility for the services the member received. The Plan denied your request. The Plan says the claim was processed accordingly with the member's 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 DME on August 12, 2019, by an in-network provider. The enrollee was asked to pay 20% coinsurance for the DME. 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 coinsurance for the DME provided to the enrollee on August 12, 2019, by an in-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the LTACH services are medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of a LTACH admission.
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. Our physician reviewer found the documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forSNF care from September 1, 2019 through September 27, 2019.You asked the Plan to waive the copayment forthe SNF care. You say that you were informed by the facility that you would be covered in full for the rehab treatment you were receiving.The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits. The Plan states the facility was given your SNF benefit when they spoke with the Plan's customer service department on August 27, 2019.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 you received SNF care from September 1, 2019 through September 27, 2019. You are responsible for a $0 copay per day, for days 1-20 and a $172 copay per day, for days 21-100. You were admitted for 34 days so the copayment was applied correctly (days 21-31 (14 days x $172 = $2,408)). 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 forSNF care from September 1, 2019 through September 27, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea SCS trial.You asked the Plan to pre-approvethe SCS trial. You say that the stimulator is no longer functional and a new version of stimulator is available.The Plan denied your request. The Plan says medical criteria was not met for this service. Lead revision would be appropriate given the documentation provided, but not SCS replacement.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 SCS trial. Our reviewer says that although a new SCS may be appropriate for this enrollee, the SCS trial is not medically necessary. A new SCS was not part of the appeal, only a SCS trial. Our decision is limited to the trial only, as this is all that was requested. The enrolleehad a successful prior placement of an SCS and there is no need for a re-evaluation of suitability for placement. In situations where the spinal cord stimulator has been working well but is in need of replacement for battery change, malfunction or end of stimulator life, a new trial is not needed to replace the stimulator.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 SCS trial have not been met.Therefore, we decided that the Plan does not have to pre-approvea SCS trial.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprovea pneumatic compression device (E0652).You asked the Plan to preapprovea pneumatic compression device. You say that the enrollee requires the device.The Plan denied your request. The Plan says the documentation did not support the 4-week trial using the basic pump that Medicare requires.The Plan follows Medicare rules. The rulesstate that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided.Therefore, we decided that the Plan does not have to preapprovea pneumatic compression device (E0652).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from June 28, 2019 to July 27, 2019.You asked the Plan to pay for the skilled nursing services. You say that the services the enrollee required and received are coverable under the Medicare Act.The Plan denied your request. The Plan says the enrollee did not require any additional skilled services that could not have been provided in an alternate setting other than a SNF.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 pay for the skilled nursing services. Our reviewer says that daily skilled services are not necessary.Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 skilled nursing services have not been met.Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from June 28, 2019 to July 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on July 3, 2019.
You asked the Plan to waive the copayment for the office visit. You say that you don't have this doctor. You say that you don't know what he did for you. 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 $35 copayment for each specialist office visit for Medicare-covered services. You have been asked to pay a $35 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show that the office visit was for a pre-procedural examination. 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 office visit provided on July 3, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) beyond the 100 day benefit limit.
You asked the Plan to pre-approve admission to a SNF beyond the 100 day benefit limit. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet criteria.
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 93 days of SNF care during the benefit period from October 5, 2019 to January 6, 2020. The Plan has partially overturned their denial and have approved the remaining 7 days of the enrollee's 100 days of SNF care for this benefit period. Once the enrollee uses the last 7 remaining days, the enrollee's current benefit period will have ended. A new benefit period will not begin until the enrollee has gone 60 days in a row without having been inpatient at any hospital or SNF. 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 admission to a skilled nursing facility (SNF) beyond the 100 day benefit limit.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvethe SpaceOAR for the enrollee.You asked the Planto pre-approvethe services. You say that this is medically necessary.The Plandenied your request. The Plansaysthe criteria is not met because the enrollee is in a high risk cancer group.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found SpaceOAR is a hydrogel spacer inserted between the rectum and prostate in order to reduce the dose exposure of the rectum-and thus rectal toxicity -in men undergoing radiation for prostate cancer. The criteria are explicit in which risks groups are covered.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules forcoverage of the services have not been met.Therefore, we decided that the Plandoes not haveto pre-approvethe SpaceOAR for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe outpatient office visit provided on August 1, 2019 by an OON provider.You asked the Plan to pay forthe office visit. The Plan denied your request. The Plan says the rendering provider is a non-participating provider with the enrollee's Plan. The Plan also says that prior authorization was not obtained.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 forthe outpatient office visit provided on August 1, 2019 by an OON provider.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approvemagnetic resonance imaging (MRI) of the shoulder (73221).You asked the Plan to pre-approvea shoulder MRI. You say that the MRI is needed to determine appropriate treatment.The Plan denied your request. The Plan says that this 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 a shoulder MRI. Our reviewer says that the requested MRI is medically necessary. Our physician reviewer found while the patient has not had a conservative course of therapy, the plain x-rays exhibit moderate degenerative joint disease, which is evidence of a longstanding shoulder problem. In order to tailor the physical therapy program to the patient's needs and avoid surgery, the requested MRI would be useful in determining the type of exercises necessary. There may be a different approach depending on the results of the MRI.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a shoulder MRI have been met.Therefore, we decided that the Plan has to pre-approvemagnetic resonance imaging (MRI) of the shoulder (73221).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 toopen 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 copayments forthe specialist office visits provided on August 23, 2019 and September 5, 2019.You asked the Plan to waive the copayments forthe specialist office visits. You say that you disagree with the copayment because you were told the colonoscopy would be free. 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 $45 copayment for each Medicare-covered specialist visit. You have been asked to pay a $45 copayment for each of the specialist office visits. The specialist office visits fall within the each "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows you were billed for the specialist office visits.This means that you have been asked to pay thecorrect 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 forthe specialist office visits provided on August 23, 2019 and September 5, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an injection on October 10, 2019 provided by the outpatient department.
You asked the Plan to waive the copayment for the injection. You say that you did not have the services done that were billed for on this date of service. You believed the provider was billing for "fluid extraction", but yoy stated you had an injection. 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). The coding used by the provider is consistent with an injection procedure at a hospital outpatient setting; therefore, you are asked to pay a $250 copayment for the services. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an injection on October 10, 2019 provided by the outpatient department.