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

We decided that the Plan does not have to waive the copayment for the outpatient services you received on December 12, 2019.You asked the Plan to waive the copayment. You say that you did not have surgery.The Plan denied your request. The Plan says you are responsible for the copayment.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $175 copayment for outpatient surgery services. Review of the file shows that you were provided outpatient services on December 12, 2019. The American Medical Association (AMA) considers procedure code 52000 to be a surgical procedure. You have been asked to pay a $175 copayment for the services. The services fall within the outpatient surgery benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment for the outpatient services you received on December 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthoses and suspension sleeves provided on November 19, 2019.
You asked the Plan to pay for the knee orthoses (L1833) and suspension sleeves (L2397). You say that the orthoses were medically necessary. The Plan denied your request. The Plan says the documentation submitted did not indicate the provider discussed the need for the billed supply codes, therefore the billed supply codes cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. The medical records do not mention or support medical necessity for the orthoses. Based on this information, we decided that Medicare rules for coverage of the knee orthoses
(L1833) and suspension sleeves (L2397) have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthoses and suspension sleeves provided on November 19, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an admission for skilled nursing facility (SNF) services, for enrollee.You asked the Plan to pre-approve the SNF services. You say that you feel the enrollee will benefit from short-term rehabilitation in a SNF.The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for SNF admission.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 medically necessary. Our physician reviewer found that from a nursing perspective, the beneficiary received oral medications. The beneficiary had stable vital signs. He was alert with confusion. Regarding rehabilitation services, the enrollee received physical therapy (PT), speech therapy (ST) and occupational therapy (OT). The enrollee was at a contact guard assist level with functional mobility including gait to 450 feet with a rolling walker. The enrollee required varying assist with activities of daily living. She had ongoing cognitive deficits.The enrollee does not require skilled nursing services. Although there are identifiable skilled therapy service needs,it is not medically necessary and reasonable to provide these skilled nursing or skilled therapy services on a "daily basis." The enrollee does  not meet 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 an admission for skilled nursing facility (SNF) services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided August 28, 2019 to September 21, 2019.You asked the Plan to pay for the SNF services. You say that you feel that the plan should cover for SNF services.The Plan denied your request. The Plan says LTACH admission to a SNF was not medically necessary. The enrollee did not require any 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing and skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis and does not meet 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 pay for the skilled nursing facility (SNF) services provided August 28, 2019 to September 21, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to charge the in-network rate for an oral appliance (E0486) provided October 2, 2019.
You asked the Plan to charge the in-network rate for the oral appliance. You say that there were no network providers and you should be charged the in-network rate of 80% coverage. The Plan denied your request. The Plan says there were in-network providers available.
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 30% coinsurance once the deductible is met for Durable Medical Equipment and supplies. You have been asked to pay a 30% coinsurance once the deductible is met for the oral appliance. the oral appliance falls within the Durable Medical Equipment 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 charge the in-network rate for an oral appliance (E0486) provided October 2, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance provided on February 5, 2020.
You asked the Plan to pay for the periodontal maintenance. You say that you went to have a cleaning. The Plan denied your request. The Plan says your dental benefits do not include coverage for periodontic services.
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 periodontal maintenance provided on February 5, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe computed tomography (CT) scan of the cervical spine rendered on August 1, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the claim is a duplicate.The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied.We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the Plan on a separate claim for the same date of service. Code 72175 was not billed with an appropriate modifier to allow for separate payment. 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 pay forthe computed tomography (CT) scan of the cervical spine rendered on August 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe initial nursing facility care (SNF) renderedby the out of network (OON) provider on November 6, 2019.You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment as the services provided were medically necessary.The Plan denied your request. The Plan says the services were provided 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 has network providers available who can provide theservice at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for thisservice.Therefore, we decided that the Plan does not have to pay forthe initial nursing facility care (SNF) renderedby the out of network (OON) provideron November 6, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an admission for SNF services.
You asked the Plan to pre-approve the SNF services. You say that you feel the enrollee will benefit from short-term rehabilitation in a SNF. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for SNF admission
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 medically necessary. Our physician reviewer found based on the medical records that the enrollee's troponin level was elevated and she was treated in the acute hospital with intravenous antibiotics for the infection. She also experienced congestive heart failure and acute kidney injury. She is very weak and deconditioned. At baseline she resides in a long-term care facility requiring moderate to maximum assistance with activities of daily living and walking with a walker. Reports from multiple providers in the hospital report that her dementia is quite advanced, oriented x 1 only, not able to understand or follow commands or participate with therapy attempts. She is reported in multiple notes to be a "very poor rehab candidate" and "more appropriate for comfort care." Our physician reviewer found that the enrollee does not require skilled nursing services. The provided medical records do not indicate a need for skilled therapy services. It is not medically necessary and reasonable to provide skilled nursing or skilled therapy services on a "daily basis." The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis
in a skilled nursing facility setting. Care in the long-term care facility with intermittent therapy services as needed appears to be appropriate. 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 an admission for 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 June 12, 2019 through June 13, 2019.
You asked the Plan to pay for acute 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 review has determined that the record did 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 for the acute inpatient hospital care provided from June 12, 2019 through June 13, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee arthroscopy to be provided by an out of network (OON) provider.You asked the Plan to pre-approve an outpatient surgery. You say that you would prefer to go to this hospital because of the low number of COVID cases.The Plan denied your request. The Plan says there are in-network providers available 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 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 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 knee arthroscopy to be provided by an out of network (OON) provider.Please contact the Plan for a list of in-network providers available.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Abraxane (J9264).
You asked the Plan to pre-approve Abraxane. You say that the requested medication is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria for a step therapy exception 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 Abraxane. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the documentation does not support that Taxol (paclitaxel) or Taxotere (docetaxel) would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Abraxane have not been met. Therefore, we decided that the Plan does not have to pre-approve Abraxane (J9264).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic maintenance care (98941) provided on December 17, 2019.
You asked the Plan to pay for chiropractic maintenance care. You say that this relieves your headaches and was covered by your previous plan. The Plan denied your request. The Plan says this is not covered under Medicare rules.
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance care. We looked at this the file and Medicare rules. Your provider has stated that you were seen in their office for maintenance care and have no acute problems. Based on this information, we decided that Medicare rules for coverage of chiropractic maintenance care have not been met. Therefore, we decided that the Plan does not have to pay for chiropractic maintenance care (98941) provided on December 17, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the assistant surgeon services provided on September 24, 2019.You asked the Plan to pay for the assistant surgeon services. 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 separately payable.The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS.In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners.Therefore, we decided that the Plan does not have to pay for the assistant surgeon services provided on September 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve advanced foot, knee, and rotational prosthesis features (L5845, L5828, L5848, L5850, L5858, L5999, L5981, L5986).
You asked the Plan to pre-approve the advanced prosthesis features. You say that the components are medically necessary. The Plan denied your request. The Plan says the advanced features exceed the enrollee's mobility abilities.
The Plan follows Medicare rules. Medicare rules say that in order to be covered, there must be sufficient clinical documentation of functional need for the technologic or design feature of a given type of knee or foot. 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 prosthesis features. Our reviewer says that the requested advanced features are not medically necessary. Our physician reviewer found the documentation notes the enrollee is currently K2 level ambulatory. The requested components are only covered for patients with K3 level mobility. The requested product exceeds the enrollee's needs and abilities 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 prosthesis features have not been met. Therefore, we decided that the Plan does not have to pre-approve advanced foot, knee, and rotational prosthesis features (L5845, L5828, L5848, L5850, L5858, L5999, L5981, L5986).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the DME provided on December 12, 2019 by an in-network provider.
You asked the Plan to waive the coinsurance for the DME. 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 show that you received the DME provided on December 12, 2019 by an in-network provider. You are asked to pay 20% coinsurance for the DME. 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 the DME provided on December 12, 2019 by an in-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on April 16, 2019 by a non-participating provider.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services were rendered by a non-participating 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 forthe medical services provided on April 16, 2019 by a non-participating provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on July 10, 2019.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee was under hospice election on the date of service in question.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on July 10, 2019.