Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for acute inpatient hospital care after an elective (LT) Arthroplasty, total shoulder surgery.

You asked the Plan to provide coverage for acute inpatient hospital care. The Plan denied your request. The Plan says the elective (LT) Arthroplasty, total shoulder has been approved as outpatient. Inpatient after care is not medically necessary based on Medicare guidelines.

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 provide coverage 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 that the enrollee is a 77-year-old female with left shoulder rotator cuff tear. The review indicates that the enrollee is undergoing a planned elective right total shoulder arthroplasty. The planned procedure listed under CPT code 23472 is not listed on the CMS Inpatient Only List. The peripheral orthopedic procedure is currently approved as an ambulatory procedure. The enrollee is medically stable. There is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay. The review has determined that the record does not show that the admitting physician reasonably expects that the enrollee's necessary hospital care will 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 provide coverage for acute inpatient hospital care after an elective (LT) Arthroplasty, total shoulder surgery.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan provided on February 12, 2021.

You asked the Plan to waive the copayment for a CT scan. You say that the CT scan is part of your physical to monitor a growth in your lungs. 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 $0 copayment for mammograms and ultrasounds and a $225 copayment for all other radiological services. 

You received a CT scan on February 12, 2021. CT scans are considered diagnostic and are not included in physical exams. Therefore, you are responsible to pay the $225 copayment.

You have been asked to pay a $225 copayment for a CT scan. A 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 waive the copayment for a CT scan provided on February 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and cone beam image capture (D0364) provided on January 20, 2021.
You asked the Plan to pay for the dental services. You say that you were not told the procedure would not be covered, and you were advised that you could go in or out of network for services. The Plan denied your request. The Plan says a cone beam image capture is not a covered service under your dental benefits. The limited oral evaluation is covered, and the Plan has paid the full allowed amount for this service. You are being charged more because you chose to use an out-of-network provider.
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. You will pay a $0 copayment for preventative and diagnostic dental services received from a participating provider. You can get care from an out-of-network dental provider, but you may pay more. 
Though the Plan offers a dental benefit in excess of Medicare coverage, a cone beam image capture is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the cone beam image capture (D0364) provided on January 20, 2021.
You have been asked to pay $129.40 for the limited evaluation. The provider billed $175, and the Plan paid the full allowed amount of $45.60. In-network providers have agreed to be paid this maximum fee and not bill any additional amount, but out-of-network providers do not have this agreement and are allowed to charge the remainder of their fee. ($175 - $45.60 = $129.40). 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 pay any additional amount for the limited oral evaluation (D0140) provided on January 20, 2021.
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 can safely receive the services needed, in other settings.

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 mental status changes, hypotension and pneumonia. The enrollee's medical conditions 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. The patient does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a shower chair provided on February 14, 2021.

You asked the Plan to pay for a shower chair. You say that your unable to stand for a complete shower and
your doctor has prescribed this as needed. The Plan denied your request. The Plan says this item is not a
covered benefit.

The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are
not primarily medical in nature.

While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this
item. Therefore, we decided that the Plan does not have to pay for a shower chair provided on February 14,
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and anoscopy provided by an out-of-network March 23, 2021.

You asked the Plan to pay for the office visit and anoscopy. You say that you were not informed your primary care physician was no longer participating in the network. You say that you did not have all the necessary information and the denial of payment should be reconsidered. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not approved in advance.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 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 office visit and anoscopy provided by an out-of-network March 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on February 11, 2021.

You asked the Plan to pay for the problem focused limited oral evaluation. You say that this service was necessary for the problem that occurred. The Plan denied your request. The Plan says this service is not covered.

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, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on February 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for specialist services provided on March 19, 2021 by an out of network (OON) provider.
You asked the Plan to pay for specialist services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.
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 had network providers available who could have provided 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 specialist services provided on March 19, 2021 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the Part B step therapy criteria has not been met.
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 the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the enrollee has not trialed viscosupplemental treatments such as Orthovisc and Monovisc. Step therapy, as outlined by the plan, requires these be trialed first. The documentation does not outline contraindications or reasons these medications were not considered or that the plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. Without the support of the documentation, Euflexxa is not approved as step criteria have not been met. 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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (88305, 88331) rendered by an out of network (OON) provider on March 3, 2021.
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 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the laboratory services (88305, 88331) rendered by an out of network (OON) provider on March 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 2 power wheelchair (PWC) (K0823).
You asked the Plan to pre-approve a PWC. You say that the item is medically necessary. The Plan denied your request. The Plan says this item is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that a group 2 PWC is covered if all of the coverage criteria (a)-(e) for a PWC are met and the wheelchair is appropriate for the beneficiary's weight. 
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 PWC. Our reviewer says that the item is not medically necessary. Our physician reviewer found that the documentation indicates the patient has a mobility deficit, but it is not clear what MRADLs in the home are impaired and not clear why the patient's mobility deficit is unable to be ameliorated by a manual wheelchair. The documentation does not reveal a home evaluation or indication that the patient is able to safely maneuver the requested wheelchair in the home and that it will significantly improve MRADL participation in the home. 
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 PWC have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 2 power wheelchair (PWC) (K0823).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on February 23, 2021.

You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics. The Plan denied your request. The Plan says these services are not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. 

The ambulance company did not provide transport services on February 23, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on February 23, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient clinic visit and pulmonary stress test provided by an out-of-network provider on October 12, 2020.

You asked the Plan to pay for the outpatient clinic visit and pulmonary stress test. You say that the attached records support the medical necessity. The Plan denied your request. The Plan says prior authorization was required but 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 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 outpatient clinic visit and pulmonary stress test provided by an out-of-network provider on October 12, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous intraoperative neurophysiology monitoring
rendered on August 11, 2020.

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 procedure code 95941 is not covered.

The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid
for Medicare purposes.

We looked at the file and Medicare rules. Procedure code 95941 has a status indicator of I and is not valid for
Medicare purposes. Therefore, we decided that the Plan does not have to pay for the continuous intraoperative
neurophysiology monitoring rendered on August 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on February 3, 2021, by an OON provider.

You asked the Plan to pay for the office visit. You say that you did not know the doctor was out-of-network. The Plan denied your request. The Plan says you received unauthorized care from an out-of-network provider.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. The file shows that notification was provided in August 2020, regarding the network status of the provider at issue.

We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the office visit provided on February 3, 2021, by an OON provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the psychotherapy (90832) rendered by the out of network (OON) provider on January 29, 2021.
You asked the Plan to pay for this service. 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 service was 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 provider in this case is not a network provider with the Plan. The Plan issued their denial as the service was rendered by an out of network provider, without prior authorization. However, the Plan contract states that enrollees can receive services from out of network providers. Additionally, the Plan does not require members or their providers to obtain prior authorization or a referral from the Plan as a condition for covering medically necessary services that are a covered benefit. Therefore, we decided that the Plan has to pay for the psychotherapy (90832) rendered by the out of network (OON) provider on January 29, 2021.
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 an office visit provided on February 9, 2021.

You asked the Plan to waive the copayment for an office visit. You say that the physician was approved as your primary care physician with no copayment. You were not informed that the provider did not accept your insurance. 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $65 copayment for out-of-network provider and professional services.

The record shows that you had an office visit with an out-of-network provider on February 9, 2021. Therefore, you are responsible to pay the $65 copayment.

The enrollee has been asked to pay a $65 copayment for an office visit. An office visit falls within the physician/practitioner services, including doctor's office visits benefit category. 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 an office visit provided on February 9, 2021.