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

We decided that the Plan does not have to waive the copayment for emergency room services provided on April 24, 2020. You asked the Plan to waive the copayment for the emergency room services. You say that you had to return for an x-ray because the staff failed to take it after your surgery so you should not have a copayment. The Plan denied your request. The Plan says you were charged this copayment correctly however you can call the provider to file a formal complaint. 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 $120 copayment for Emergency Care. You have been asked to pay a $120 copayment for the emergency room services. The emergency room services fall within the Emergency Care 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 emergency room services provided on April 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not have to pre-approvea whirlpool walk-in tub (T2028 U3).You asked the Plan to pre-approvea whirlpool walk-in tub. You say that you would like to appeal the denial.The Plan denied your request. The Plan says is not listed and is not covered as it is not considered reasonable and necessaryThe Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  There are more cost effective alternatives that the enrollee was notopen to. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plan does not have to pre-approvea whirlpool walk-in tub (T2028 U3).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay foran eye refraction received on August 14, 2020.You asked the Plan to pay forthe services. You say that this should be paid for.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 does not cover refractionThe services you asked the Plan to pay for are considered refraction.Therefore, we decided that the Plan does not have to pay foran eye refraction received on August 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on June 9, 2020 by an out of network (OON) 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 an out-of-network provider without prior authorization.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan 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 forthe medical services provided on June 9, 2020 by an out of network (OON) provider
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet 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 admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is with generalized weakness, cough and bilateral lower extremity swelling. The enrollee is Covid positive and has acute on chronic heart failure. From a nursing perspective, the enrollee received oral medications and insulin. The enrollee had stable vital signs. Regarding rehabilitation services, the enrollee received physical therapy in the acute hospital. The enrollee was at a moderate to maximal assist level with bed mobility and he required a mechanical lift for transfers.  

There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. This 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 admission to a SNF have not been met.Therefore, we decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF).
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to hold you harmless for the CT Scan (G0297) provided.

You asked the Plan to hold you harmless for the CT Scan. You say that you would like reconsideration because your doctor referred you for the CT Scan.The Plan denied your request. The Plan says that this code has been billed with a GZ modifier and is not payable.

Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules.

You were referred for the CT Scan by a contract provider. The file does not show that the Plan provided notice that the CT Scan would not be covered. Under Medicare rules, this means the CT Scan is considered approved by the Plan.Therefore, we decided that the Plan has to hold you harmless for the CT Scan (G0297) provided.

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a spinal electrical osteogenesis stimulator (E0748).
You asked the Plan to pre-approve a bone growth stimulator. You say that the claim should be paid. The Plan denied your request. The Plan says experimental and investigational devices are not covered.
The Plan must follow Medicare rules. The rules say that an electrical bone stimulator is covered for the conditions above, and for all others is to be considered experimental and investigational. We asked our 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 bone growth stimulator. Our reviewer says that the device does not meet Medicare criteria for coverage. Our physician reviewer found an E0748 is considered experimental and investigational when used as an adjunct to cervical spinal fusion surgery. Nine months should have elapsed since last surgery. We looked at this review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a bone growth stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve a spinal electrical osteogenesis stimulator (E0748).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe critical care services coded 99292 provided on May 27, 2020.You asked the Plan to pay forthe critical care services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not supported by the documentation.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 99292 is critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for primary service).We find that CPT code 99292 is not supported in the medical record. Specifically, this code represents an additional 30 minutes of critical care time in addition to the first 30-74 minutes of a critical care evaluation and management service (Current Procedural Terminology (CPT) code 99291). The submitted medical records document 70 minutes of critical care time. They do not support that an additional 30 minutes of critical careservices was performed in addition to the first 30-74 minutes of a critical care evaluation and management service (Current Procedural Terminology (CPT) code 99291)to support the billing of Current Procedural Terminology (CPT) code 99292. Based on this information, we decided that Medicare rules for coverage of the critical care services have not been met. Therefore, we decided that the Plan does not have to pay forthe critical care services coded 99292 provided on May 27, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveAmbien.You asked the Plan to pre-approveAmbien. You say that the enrollee has used Ambien for the past several years, and it has helped her control her insomnia.The Plan denied your request. The Plan says this medication is not covered under Part B.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approveAmbien.Benefits for Ambienmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible forthe office visit provided on July 28, 2020.You asked the Plan to waive the deductible forthe office visit. You say that you only have a $35 copayment which you paid.The Plan denied your request. The Plan says you have a deductible which you had not met at the time of service.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 there is a $250 deductible for covered Medicare Part A and B services.The item or service you asked the Planto waive the deductible for falls within the benefit category covered Part B services.The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $250 deductible for covered Part B services. This cost sharing is a contractual obligation that had not been met at the time the office visit was received on July 28, 2020.Therefore, we decided that the Plan does not have to waive the deductible forthe office visit provided on July 28, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a portable oxygen concentrator (POC). You asked the Plan to pre-approve the concentrator. You say that this is medically necessary. The Plan denied your request. The Plan says that the enrollee has been provided with a home fill system to refill the portable D-Tanks. The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify for oxygen solely based on blood gas studies obtained during sleep. 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 concentrator. Our reviewer says that the requested concentrator is medically reasonable and necessary. Our physician reviewer found you are unable to carry or pull the D-tank for portable oxygen due to pain and bone metastases. You need a walker for stability. The requested POC is medically necessary for ambulation in and out of the home. You are on 2 L/min with a conserving device. 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 concentrator have been met. Therefore, we decided that the Plan has to pre-approve a portable oxygen concentrator (POC).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay forthe physical therapy services received January 1, 2020 to January 26, 2020 and to waive the copayment for the physical therapy services received from January 27, 2020 to April 25, 2020.You asked the Plan to pay forthe physical therapy services received January 1, 2020 to January 26, 2020 and to waive the copayment for the physical therapy services received from January 27, 2020 to April 25, 2020. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services have been processed per the enrollee's plan 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 enrollee'scontract with the Plan clearly says that enrolleesmust pay a $40 copayment for outpatient rehabilitation services.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, outof area urgent care and pre-approved care. The enrollee has been asked to pay for the physical therapy services received January 1, 2020 to January 26, 2020. The enrollee has also been asked to pay a $40 copayment for each of the physical therapy services received January 27, 2020 to April 25, 2020. The rendering 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 received January 1, 2020 to January 26, 2020.The physical therapy services fallwithin the outpatient rehabilitation services benefit category. The plan changed their guidance for out of network services for any services received on or after January 27, 2020, the services will waive prior authorization/ precertification and referral requirement penalties. Therefore, the services received January 27, 2020 to April 25, 2020 were processed and paid at the in-network benefit level minus any cost share requirement. 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 forthe physical therapy services received January 1, 2020 to January 26, 2020 and to waive the copayment for the physical therapy services received from January 27, 2020 to April 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided.

You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.

Medicare rules say that plans can require enrollees to get care from network providers. The contract withthe 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 physician's services. We found no exception that would require the Plan to pay forthese services. Therefore, we decided that the Plan does not have to pay for physician's services provided.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on August 20, 2020.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they 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 laboratory services. 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 laboratory services provided on August 20, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing rendered on August 5, 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 the services were not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that definitive drug testing 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 pay for these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the results of the testing were negative and the negative finding was inconsistent with the enrollee's medical history. In this case, the provider did not submit progress notes that were needed in order to determine the clinical utility of the testing. The testing was therefore not reasonable or 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 pay for the definitive drug testing rendered on August 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecompression stockings identified with code A6530.You asked the Plan to pre-approvethe compression stockings. You say that you'd like a reconsideration, that the stockings would greatly benefit the enrollee.The Plan denied your request. The Plan says the compression stockings are excluded from coverage.The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan.Therefore, we decided that the Plan does not have to pre-approvecompression stockings identified with code A6530.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe Vertiflex device surgery (22869, 22870).You asked the Plan to pre-approvethe Vertiflex surgery. You say that this service is medically necessary.The Plan denied your request. The Plan says the requested surgery is 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 pre-approve the Vertiflex surgery.Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is imaging evidence of S-shaped scoliosis of the lumbar spine with no documentation of the Cobb angle. There is no documentation of a dual-energy X-ray absorptiometry (DEXA)scan demonstrating no osteoporosis in this post-menopausal 79-year-old female. Current evidence based medical guideline and peer reviewed literature do not fully support the spinal decompression device procedure over the 'gold standard' of lumbar laminectomy.  Superion indirect lumbar decompression would not be considered the standard of care for the enrollee's medical condition.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 Vertiflex surgery have not been met.Therefore, we decided that the Plan does not have to pre-approvethe Vertiflex device surgery (22869, 22870).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) services provided April 20, 2020 to June 1, 2020. You asked the Plan to waive the copayment for the SNF days. You say that the admissions coordinator told you that you her care would be covered at 100% by the insurance. There is no itemization or explanation as to why you are financially liable. The Plan denied your request. The Plan says this claim was processed correctly per the Evidence of Coverage.
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 $0 copayment per day, days 1-20 $178 copayment per day, days 21-100 for Skilled nursing facility (SNF) care. You have been asked to pay $3,916.00 ($178 x22 days) for the SNF days. Your SNF coverage began April 0,2020 and you had $0 copay. Your copay kicked in May 11, 2020 and you are responsible for $178 for the 22 days. The SNF days falls within the Skilled nursing facility (SNF) care 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 skilled nursing facility (SNF) services provided April 20, 2020 to June 1, 2020.