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

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on November 12, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the subsequent nursing facility care. 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 a covered benefit.

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 the subsequent nursing facility care provided on November 12, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the transtelephonic evaluation services provided on July 2, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. You say that the services were provided in good faith. The Plan denied your request. The Plan says authorization for out-of-network services was not obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The 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 transtelephonic evaluation services provided on July 2, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye exam (92014, 92202) provided on July 8, 2020.

You asked the Plan to waive the copayment for the eye exam. You say that the Plan said they would waive all copayments through 2020 due to the pandemic. The Plan denied your request. The Plan says Medicare-covered vision services for the diagnosis and treatment of diseases and injuries of the eye require a $50 copayment. In addition, the only copayments that are waived in 2020 are copayments for in-network primary-care visits, in-network behavioral health outpatient visits, and in-network telehealth visits. The Plan is not waiving other cost shares at this time.

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 $50 copayment for Medicare-covered vision services. 

You have been asked to pay a $50 copayment for the eye exam. The eye exam falls within the Medicare-covered vision services 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 eye exam (92014, 92202) provided on July 8, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for continuation of an inpatient admission from
January 17, 2020, through January 20, 2020.
You asked the Plan to pre-approve continuation of an inpatient admission. You say that this level of patient care has been substantiated by the clinical evidence presented. The Plan denied your request. The Plan says the enrollee had no new complaints; vital signs and labs stable; shortness of breath improved and was weaned off BiPAP. AV fistula being used for dialysis. The enrollee was stable awaiting SAR subacute rehab placement. Does not meet criteria for continued inpatient stay.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for continuation of an inpatient admission from January 17, 2020, through January 20, 2020. Our reviewer says that the requested continuation of the inpatient admission is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was a then a 79-year-old man who was admitted to the hospital on January 9, 2020 with systemic inflammatory response syndrome (SIRS), and acute respiratory failure. The Plan approved an inpatient admission from January 9, 2020, through January 16, 2020. The Plan maintains that the enrollee was stable and was awaiting placement in a subacute rehab facility during this time frame. The enrollee's medical history was notable for COPD, hypertension, and chronic kidney disease. The enrollee required BiPAP for respiratory
failure. Antibiotics were administered. Dialysis was necessary for the treatment of renal failure. The enrollee had been weaned off BiPAP, however due to lethargy and hypercarbic respiratory failure, the enrollee was placed back on BiPAP on 1/16/2020. On January 17, 2020, the enrollee was back at his baseline. The reason for continued hospitalization was documented to be "pending placement". On January 19, 2020, the enrollee's respiratory failure had resolved, and antibiotics were due to end. The enrollee was to go to rehab and was to continue dialysis. The available documentation in the case file does not support that continued inpatient admission from January 17, 2020 through, January 20, 2020 was medically reasonable and necessary 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 continuation of an inpatient admission have not been met. Therefore, we decided that the Plan does not have to pay for continuation of an inpatient admission from January 17, 2020, through January 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug provided on January 11, 2021.

You asked the Plan to waive the coinsurance for a Medicare Part B drug. You say that you cannot afford the charges. 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 co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for Medicare Part B prescription drugs.

You received a Medicare Part B drug provided on January 11, 2021. The total allowed amount is $1,847.26 and 20% of that is $369.45.

You have been asked to pay the total coinsurance amount of $369.45 for a Medicare Part B drug. A Medicare Part B drug falls within the Medicare Part B prescription drugs 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 coinsurance for a Medicare Part B drug provided on January 11, 2021.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for hyperbaric oxygen therapy (G0463, G0277) provided September 14, 2020 to September 15, 2020.
You asked the Plan to waive the copayment for the hyperbaric oxygen therapy. You say that the copayments should be waived. The Plan denied your request. The Plan says the correct copayment was applied.
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 Hospital services. You have been asked to pay a $175 copayment for the hyperbaric oxygen therapy provided September 14, 2020. The plan discounted rate of $88.32 was applied for September 15, 2020. The hyperbaric oxygen therapy falls within the Outpatient Hospital services 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 hyperbaric oxygen therapy (G0463, G0277) provided September 14, 2020 to September 15, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for individual psychotherapy, 30 minutes (90832) provided on June 30, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the psychotherapy services. You say that the enclosed medical records clearly reflect the medical necessity for the services rendered. Please process the enclosed documents at the earliest and reprocess the claim for payment. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 individual psychotherapy, 30 minutes (90832) provided on June 30, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee from June 18, 2020, to October 29, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider has opted out of Medicare.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. 

The services at issue in this appeal were provided in a non-urgent, non-emergent situation by a provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the services provided to the enrollee from June 18, 2020, to October 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodontal scaling and root planing (D4341) provided on December 3, 2020.

You asked the Plan to pay for the periodontal services. You say that these services were medically necessary. The Plan denied your request. The Plan says this service is not covered by Medicare or by the Plan's supplemental dental benefit.

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 periodontal scaling and root planing (D4341) provided on December 3, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF 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 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. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for left lower extremity hematoma after a motor vehicle accident. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for adjustable six chamber bed provided on October 1, 2020 to October 7, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the adjustable six chamber bed. You say that the bed greatly improves your sleep, pain, and is overall beneficial for you. The Plan denied your request. The Plan says you received services from non-participating providers who are not Medicare Certified for durable medical equipment therefore, the claim denied correctly.
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 adjustable six chamber bed provided on October 1, 2020 to October 7, 2020 by an out of network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care and debridement services provided on November 19, 2020
You asked the Plan to pay for the subsequent nursing facility care and debridement services. You say that the services were provided prior to obtaining authorization to avoid delay in care which could result in wound complications. The Plan denied your request. The Plan says the enrollee elected hospice from November 6, 2020, to November 27, 2020. The Plan also says that Original Medicare is responsible for this service.
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 the subsequent nursing facility care and debridement services provided on November 19, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of the enrollee's 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on January 20, 2021.
You asked the Plan to waive the copayment for a specialist visit. You say that this was a routine primary care provider visit and disagree with the charges. 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 $10 copayment for specialist visits. The record shows that you received a specialist visit on January 20, 2021. Therefore, you are responsible to pay the $10 copayment. You have been asked to pay a $10 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits 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 specialist visit provided on January 20, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the services (99606, 99607) provided on November 16, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the services are not covered.
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 provided the services by a contract provider. The file does not show that the Plan provided notice that the services would not be covered. Under Medicare rules, this means the services is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the services (99606, 99607) provided on November 16, 2020.
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF 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 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. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for weakness and dizziness. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network provider on November 11, 2020.
You asked the Plan to pay for the 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 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 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 services provided to the enrollee by an out-of-network provider on November 11, 2020.