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

We decided that the Plan has to pre-approve four levels of RFA. We decided that the Plan does not have to pre-approve an additional 2 levels of RFA.You asked the Plan to pre-approve 6 levels of RFA. You say that you would like reconsideration based on the records submitted.The Plan says that the member does not meet Medicare coverage criteria for RFA.We decided that the Plan has to pre-approve four levels of RFA.The Plan follows Medicare rules. Medicare rules say that for each covered spinal region no more than two (2) thermal RF sessions will be reimbursed in any 12-month period, involving no more than four (4) joints per session, e.g., two (2) bilateral levels or four (4) unilateral levels.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 RFA. Our reviewer says that the maximun number of RFA joints is 4 per session as per the LCD, not six. Our physician reviewer found 2 levels bilaterally would be deemed medically reasonable and 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 RFA have been met. Therefore, we decided that the Plan has to pre-approve RFA, 2 levels bilaterally or 4 unilaterally. We also decided that the Plan does not have to pre-approve an additional 2 levels of RFA.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an additional 2 levels of RFA have not been met. Therefore, we decided that the Plan does not have to pre-approve the additional 2 levels of RFA.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 long term acute care hospital (LTACH) services.You asked the Plan to pre-approve the LTACH services. You say that the LTACH admission is medically necessary. The Plan denied your request. The Plan says the member is receiving appropriate care in their current setting and does not require a transfer to a LTACH.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan.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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe hospital discharge services rendered on August 24, 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 procedure code 99239 is not supported.The Plan must follow Medicare rules. Medicarerules 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 99239 is hospital discharge day management; more than 30 minutes.We find that CPT code 99239 is not supported in the medical record. Specifically, there is no documentation of more than 30 minutes of discharge services spent on the enrollee. 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 hospital discharge services rendered on August 24, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe physical therapy visit provided on October 9, 2019.You asked the Plan to waive the copayment forthephysical therapy visit. You say that you should not be responsible for the copayment because the provider did not inform you of the $40 copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $40 copayment for each physical, occupational, and/or speech/language therapy visit. You have been asked to pay a $40 copayment for the physical therapy visit. The physical therapy visit falls within the "Outpatient rehabilitation 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 forthe physical therapy visit provided on October 9, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe X-ray of the lumbar spine (72100) provided on August 26, 2019 by out of network provider.You asked the Plan to pay forthe x-ray. You say that the services were medically necessary.The Plan denied your request. The Plan says the services were not emergent or pre-authorized. The network has providers that can provide the same service.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 urgentcare 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 service 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 X-ray of the lumbar spine (72100) provided on August 26, 2019 by out of network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plandoes not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.You asked the Plan to pre-approve the admission. You say that this is medically necessary.The Plandenied your request. The Plan says care can be received in another setting.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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or 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 admission have not been met.Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient lab work provided on August 20, 2019 by out of network provider. You asked the Plan to pay for outpatient lab work. You say that your company does not see the patient. You say that all you do is handle the lab work that has been sent to you.The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the referring provider is also out-of-network.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 for outpatient lab work provided on August 20, 2019 by out of network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for X-rays provided on October 2, 2019 and October 25, 2019.You asked the Plan to waive the copayments for X-rays. You say that you 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 $35 copayment for X-rays.You received X-rays from October 2, 2019 to October 25, 2019. Therefore, you are responsible to pay the total allowed amount of $50.04, which is less than the total copayment amount.  You have been asked to pay $50.04 for X-rays. X-rays fall within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayments for X-rays provided on October 2, 2019 and October 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foran office visit (99213) provided on July 24, 2019 by out of network provider.You asked the Plan to pay foran office visit. You say that you are appealing the denied claim, seeking a review and requestingpayment.The Plan denied your request. The Plan says the non-urgent services are not authorized because the doctor is a non-network provider with the member's health plan, and member self-directed. The member's network primary care physician (PCP) did not refer for services. The health plan requires utilization of network providers when possible and available and requires authorization for certain services. No medicalnecessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.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 foran office visit (99213) provided on July 24, 2019 by out of network provider.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay forthe services provided on August 30, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says that the billed services were misrepresented.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The plan contends that the billed services were misrepresented, and that the documentation indicates that fraud and abuse has been committed. While there may be evidence of fraudulent billing in this case, the plan has not clearly pointed to any evidence supporting its denial.Therefore, we decided that the Plan has to pay forthe services provided on August 30, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lab services provided on May 29, 2019.You asked the Plan to pay forthe lab services. The Plan denied your request. The Plan says the documentation submitted did not include a physician order/lab requisition or medical records stating exactly what tests are to be performed.The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met.Therefore, we decided that the Plan does not have to pay forthe lab services provided on May 29, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refraction rendered to you on October 15, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plandenied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. The services you asked the Plan to pay for are considered routine vision services or eyewear.Therefore, we decided that the Plan does not have to pay forthe eye refraction rendered to you on October 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility services provided on September 3, 2019 by out of network provider.You asked the Plan to pay forskilled nursing facility services. You say that you would like this claim reprocessed and approved or payment.The Plandenied your request. The Plan says no prior authorization was obtained. The Plan says that the nursing facility is also out-of-network.Medicare rules say that plans can require enrollees to get care from network providers. Thecontract 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 forskilled nursing facility services provided on September 3, 2019 by out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing services provided on August 28, 2019.You asked the Plan to pay forthe drugtesting services. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order/lab requisition or medical records.The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met.Therefore, we decided that the Plan does not have to pay forthe drug testing services provided on August 28, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a porcelain crown, prefabricated post and core in addition to crown, and post removal.You asked the Plan to pre-approve the porcelain crown, prefabricated post and core, and post removal. The Plan denied your request. The Plan says these services are not covered under your benefit plan. The Plan also says that the services you have requested are restorative dental services and you only have coverage for preventive dental 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 pre-approvea porcelain crown, prefabricated post and core in addition to crown, and post removal.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forspecialist services provided on July 23, 2019 by out of network provider.You asked the Plan to pay forspecialist services. You say that the patient provided us with his traditional Medicare insurance on this date of service and we were unaware that he had a plan we do not participate with the physician.The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that there is no referring provider listed on this claim.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 forspecialist services provided on July 23, 2019 by out of network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve injection of romosozumab (Evenity).You asked the Plan to pre-approveEvenity. You say that you are appealing with medical records.The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because the enrollee does not meet the criteria for coverage of this drug.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 pre-approve Evenity. Our reviewer says that the enrollee does not meet the Medicare criteria for use of Evenity. Our physician reviewer found the documentation submitted does not outline previous medications tried to treat osteoporosis, nor does it include blood vitamin levels. Medicare drug compendia state Evenity is not a first line agent for treatment of osteoporosis. Additionally, Food and Drug Administration (FDA) guidelines support the use of Evenity for age-related osteoporosis but not chronic Prednisoneuse. Therefore, the medical necessity of Evenity is not established.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Evenity have not been met.Therefore, we decided that the Plan does not have to pre-approveinjection of romosozumab (Evenity).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve shoulder surgery for the enrollee.You asked the Plan to pre-approve the surgery. You say that this is medically necessary.The Plan denied your request. The Plan says there is no documentation of any conservative therapy.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 surgery. Our reviewer says that the requested surgery is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation of a recent trial and failure of conservative measures to include PT. Surgery is not needed 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 surgery have not been met.Therefore, we decided that the Plan does not have to pre-approve shoulder surgery for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from May 9, 2019 through May 15, 2019.You asked the Plan to waive the copayment forinpatient hospital care. You say that you are appealing your cost-share responsibility for the services you received.The Plandenied 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 shows that you were admitted on May 9, 2019 and discharged on May 15, 2019. You were asked to pay a $395 copayment per day from May 9, 2019 through May 13, 2019, days 1-4 of your inpatient stay. There were no copayment charges fromMay 14, 2019, day 5 of your inpatient hospital care until your day of discharge May 15, 2019. Per your contract there is a $395 copayment per day required for days 1-4. 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 forinpatient hospital care provided from May 9, 2019 through May 15, 2019.