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

We decided that the Plan does not have to waive the copayment for SNFcare from November 1,2019 through November 22, 2019.You asked the Plan to waive the copayment for SNF care. You say that the doctor ordered you to stay two (2) more weeks, no one advised you that you would have to pay for the last week that you were there.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).Medical records substantiate that you received skilled nursing level of care from October 25, 2019 through November 22, 2019. The contract states that a $170.50 copayment per day applies for skilled nursing facility services rendered on days 21-100 of a benefit period. This copayment is a contractual obligation that the member agreed to pay upon enrolling with the Plan and cannot be waived or reduced. As medical records substantiate that skilled nursing facility services were rendered for a total of 29days, we have determined that no copayment applies for days1-20 of your SNF benefit period, but that you will remain liable for $1,365.00 which is $170.50 per day for days 21-28 of the SNF benefit period. Please note, no copayment was assessed for the day of discharge. 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 SNF care from November 1, 2019 through November 22, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF care. You say that the stay is 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 IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found based on the documentation provided, it is my opinion that the health plan's denial should be upheld. The enrollee does notrequire the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care (ex.SNF/SAR, outpatient rehabilitation).We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on March 5, 2019.
You asked the Plan to pay for the lumbar-sacral orthosis (L0650). You say that the orthosis is medically necessary. The Plan denied your request. The Plan says the orthosis is not 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 pay for the lumbar-sacral orthosis (L0650). Our reviewer says that the orthosis is not medically necessary. Our physician reviewer found the enrollee's chief complaint was back pain. The available documentation in the case file does not support that the requested lumbar-sacral orthosis was medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. An appropriate history and a physical examination of the back would reasonably be required to adequately assess whether the coverage criteria for a Lumbar-sacral orthosis have been met. The documentation does not support that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as there is insufficient documentation of a credible physical examination of the back. 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 lumbar-sacral orthosis (L0650) have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on March 5, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Abatacept injection (J0129).
You asked the Plan to pre-approve the Abatacept injection. The Plan denied your request. The Plan says there is no reason why step-therapy should not be followed. The Plan also says that before this drug is covered, the enrollee must try Inflectra or Renflexis.
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 Abatacept injection. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee has not tried and failed the required drugs, Inflectra or Renflexis (infliximab). Our reviewer also found that the documentation does not support that Inflectra (Infliximab-dyyb) or Renflexis (Infliximab-abda) 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 the Abatacept injection have not been met. Therefore, we decided that the Plan does not have to pre-approve the Abatacept injection (J0129).
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from September 5, 2019 through September 7, 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 that 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 supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that that the record showed 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 been met.Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from September 5, 2019 through September 7, 2019.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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on September 23, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the services were not authorized.Medicare rules say that plans can require enrollees to get care fromnetwork 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 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 forthe medical services provided to the enrollee by an out-of-network provider on September 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on November 26, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says there is no network deficiency 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 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 networkproviders available who can provide 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 forthe medical services provided to the enrollee by an out-of-network provider on November 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network orthopedic specialist.You asked the Plan to pre-approve these services. You say that you have severe hip pain.The Plan denied your request. The Plan says the services are available from network providers.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approve a referral to an out-of-network orthopedic specialist
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from June 21, 2019 through
June 24, 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 that 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 supports that the criteria for inpatient payment are met in this case. Our physician
reviewer found the record does 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. Inpatient admission was 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 acute inpatient hospital care have been met. Therefore, we decided that the Plan
has to pay for the acute inpatient hospital care provided from June 21, 2019 through June 24, 2019.
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 deductible for an office visit provided on June 10, 2019.
You asked the Plan to waive the deductible for an office visit. You say that the enrollee already met the deductible with Medicare and should not be responsible for the charges. The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. The enrollee's contract with the Plan says that there is a $185 deductible for Medicare Part B services. The record shows that the enrollee had paid $0 toward the $185 deductible prior to receiving an office visit on June 10, 2019. Therefore, the enrollee is responsible to pay the allowed amount of $33.18. The item or service you asked the Plan to waive the deductible for falls within the benefit category physician/practitioner services, including doctor's office visits. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $185 deductible for Medicare Part B services. This cost sharing is a contractual obligation that had not been met at the time an office visit was received on June 10, 2019. Therefore, we decided that the Plan does not have to waive the deductible for an office visit provided on June 10, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the LifeVest provided on December 10,
2019.
You asked the Plan to waive the coinsurance for the DME. You say that you were told by the Plan that you
would be covered at no cost. The Plan denied your request. The Plan says they reviewed your call placed to the
Plan on December 9, 2019 and there is no evidence of such allegation.
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 LifeVest provided on December 10, 2019. 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 LifeVest provided on
December 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on June 5, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe medical services. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services received were neither emergent nor urgent and prior authorizationwas not obtained to seek out-of-network care.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 June 5, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral for laser light-force therapy.You asked the Plan to pre-approve these services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. Medicare rules say that infrared therapy is not covered.We looked at the file and Medicare rules. The requested services are infrared therapy for the treatment of neuropathy. These services are denied by Medicare as not covered.Therefore, we decided that the Plan does not have to pre-approve a referral for laser light-force therapy
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wireless capsule endoscopy.You asked the Plan to pre-approve the services. You say that this is medically necessary.The Plan denied your request. The Plan says this is not considered medically necessary unless a colonoscopy has been performed along with an upper gastrointestinal endoscopy.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 services are not considered medically reasonable and necessary in this case. Our physician reviewer found the criteria was not met, as there is an absence of a current colonoscopy that excludes lower GI sources of hemorrhage.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 services have not been met.Therefore, we decided that the Plan does not have to pre-approve a wireless capsule endoscopy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for 2D oral/facial photographic image obtained intra-orally or extra-orally x 3 (D0350) provided on December 20, 2019.
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says this service is not listed in your EOC as a covered benefit; therefore, it 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. This is not a covered benefit. As an alternative, the provider will not be charging you for this service. Therefore, we decided that the Plan does not have to pay for 2D oral/facial photographic image obtained intra-orally or extra-orally x 3 (D0350) provided on December 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient hospital services provided to the enrollee from March 1, 2019 to March 29, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says there is an invalid/missing modifier - ESA codes must include a route of administration modifier.
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 HCPCS code Q4081 is "Injection, epoetin alfa, 100 units (for ESRD on dialysis)." 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 services. Our reviewer says that the services at issue in this case were not coded correctly. Our physician reviewer found HCPCS code Q4081 was not submitted to the health plan with a required modifier of JA - to indicate an intravenous administration or modifier JB - to indicate a subcutaneous administration, therefore this code is not eligible for reimbursement from March 1, 2019 to March 29, 2019.
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 services have not been met. Therefore, we decided that the Plan does not have to pay for outpatient hospital services provided to the enrollee from March 1, 2019 to March 29, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a Group 3 power wheelchair upgraded electronics.
You asked the Plan to provide the power wheelchair Electronic connection (E2311), Expandable controller harness (E2313), and Expandable controller (E2377). You say that the advanced electronics are needed for the multiple power options. The Plan denied your request. The Plan says there is no medical need to control the power options through the joystick.
The Plan follows Medicare rules. Medicare rules state that 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. Documentation shows that the enrollee has normal range of motion and 4/5 strength in the bilateral upper limbs. Upper limb strength and range of motion are adequate for the enrollee to be able to control the power options using their own switches which are included in the allowance of these power options. This means that
Medicare rules for coverage of a PMD options have not been met. Therefore, we decided that the Plan does not have to provide a Group 3 power wheelchair upgraded electronics
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on August 7, 2019.
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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a
physician.
We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation.
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 drug testing rendered on August 7, 2019.