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

We decided that the Plan does not have to pay for the evaluation and management services provided on February 20, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the OON services. You say that the claim was denied in error. The Plan denied your request. The Plan says the enrollee's plan requires utilization of network providers, and authorization for certain 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 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 evaluation and management services provided on February 20, 2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that you need IRF care. The Plan denied your request. The Plan says the rules for IRF care have not been met.

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 that you were admitted for hypotension and neutropenia and was discharged home on August 2, 2021. Medical conditions are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. Although you do require physical and occupational therapy, there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. In conclusion, there is not a reasonable expectation that you 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for nursing facility discharge services provided on September 8, 2020.

You asked the Plan to pay for the nursing facility discharge services. The Plan denied your request. The Plan says there are no referrals or authorization on file from the member's PCP after the custodial start date.

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 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 nursing facility discharge services provided on
September 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional periapical x-rays (D0230 x 2), the oral hygiene instructions (D1330), and the topical application of fluoride varnish (D1206) provided on February 18, 2021.

You asked the Plan to pay for the dental services. You say that you thought you received a teeth cleaning. You say that you had never had a topical application of fluoride done before. You say that your doctor should have checked with your plan to see if that type of cleaning was covered. You also say that you feel that you are not responsible for these services. The Plan denied your request. The Plan says 1 periapical x-ray is covered per calendar year. The Plan says that the frequency limit has been exceeded. The Plan says that oral hygiene instruction and fluoride varnish application are not listed as covered services. The Plan also says that you were advised prior to the date of service that your dental coverage is code specific.

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 and periapical x-rays are listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for the initial periapical x-ray that you received on the date of service in this case. Additionally, oral hygiene instructions and fluoride varnish application are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the additional periapical x-rays (D0230 x 2), the oral hygiene instructions (D1330), and the topical application of fluoride varnish (D1206) provided on February 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed (E0261).
You asked the Plan to pre-approve the hospital bed. You say that the enrollee requires a hospital bed due to side effects of treatment, which includes fatigue, loss of balance, unsteady gait. The Plan denied your request. The Plan says the records do not support that the requested semi-electric hospital bed is medically necessary.
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient: 1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 2. Requires attachments which can only be attached to a hospital bed; AND 3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 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 hospital bed. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation indicates the member has breast cancer and is undergoing chemotherapy which leaves her feeling week. There is no indication she has any pressure injuries or need for positioning that would not be possible in a non-electric bed. It is unclear why the member would require a semi-electric hospital bed. 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 hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve a semi-electric hospital bed (E0261).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for molecular pathology testing provided to the enrollee on August 7, 2020.
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 the diagnosis does not substantiate this service.
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 the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee has diagnoses of abnormal pulmonary function studies. The review indicates that there is no clinical rationale for the obtained molecular pathology testing obtained on August 7, 2020. The enrollee does not have a proper diagnosis for this service.
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 molecular pathology testing provided to the enrollee on August 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the echocardiogram and the ECG provided on March 22, 2021 and March 31, 2021.

You asked the Plan to waive the copayments for the echocardiogram and the ECG. You say that you were told that these charges are not your responsibility. You say this is a lot of extra money for you to pay. The Plan denied your request. The Plan says you have been asked to pay 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 $35 copayment for each outpatient x-ray, diagnostic procedure and test.

You have been asked to pay a $35 copayment for the echocardiogram and a $14.80 copayment, which is less than the standard copayment amount for the ECG. ($35 + $14.80 = $49.80). The echocardiogram and the ECG 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 the echocardiogram and the ECG provided on March 22, 2021 and March 31, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the $10 copayment charged for outpatient mental health care provided on February 17, 2021.
You asked the Plan to waive this copayment. You say that copayments were waived due to Covid-19. The Plan denied your request. The Plan says as a courtesy during Covid-19 for part of 2020, copayments for these types of services were waived from May 11, 2020, to December 31, 2020. Copayments for services provided in 2021 were no longer being waived.
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 $10 copayment for outpatient mental health care. 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 $10 copayment charged for outpatient mental health care provided on February 17, 2021.
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 service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.
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 patient does not require skilled nursing or skilled therapy services. 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. Specifically, medically necessary services can be obtained at a lower level of care. This means admission into a SNF is not medically necessary. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the intraoral x-ray and extraction provided March 17, 2021.
You asked the Plan to pay more for the intraoral x-ray and extraction. You say that you were never notified about the difference of in and out-of-network providers with the dental plan. You say that you cannot afford this bill. The Plan denied your request. The Plan says the claim processed correctly.
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 Plan also has a $100 deductible that applies to extractions. You are also responsible for any amount greater than the payment made by the Plan to the out-of-network provider. Therefore, we decided that the Plan does not have to pay more for the intraoral x-ray and extraction provided March 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the transthoracic echocardiography (93306) and the myocardial perfusion imaging (78452) provided on September 3, 2020.
You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to the services provided.
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 each Original Medicare covered diagnostic test or procedure. Additionally, you must pay a $400 copayment for each covered nuclear medicine study.
You have been asked to pay a $410 copayment for the diagnostic test and the nuclear medicine study provided. 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 the transthoracic echocardiography (93306) and the myocardial perfusion imaging (78452) provided on September 3, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the pathology services provided on January 11, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the OON services. You say that the services were performed at a preferred provider's office. The Plan denied your request. The Plan says the services were not urgent, emergent, or 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 provider in this case is not a network provider with the Plan. The services were not referred by 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 pathology services provided on January 11, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the lab services provided on March 22, 2021.

You asked the Plan to waive the copay for the services provided. You say that the labs should have been paid
in full. The Plan denied your request. The Plan says the claim processed correctly.

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
copay for each outpatient hospital visit for lab services.

The file shows that the lab services were billed by an outpatient hospital facility. You have been asked to pay
$23.11 for the services provided. Because the amount is less than the $40 copay, you were charged the lesser
amount. The services fall within the lab 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
copay for the lab services provided on March 22, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Alimta (J9305).
You asked the Plan to pre-approve Alimta. You say that this is medically necessary. The Plan denied your request. The Plan says this drug is not supported in combination with the other drugs being used to treat the enrollee.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Alimta. Our reviewer says that the requirements for coverage of Alimta have not been met. Our physician reviewer found Alimta is not FDA-approved for the enrollee's diagnosis. It is indicated for non-squamous histology and this patient has squamous cell non-small cell lung cancer. This use is also not supported by one of the major drug compendia or by clinical research. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Alimta have not been met. Therefore, we decided that the Plan does not have to pre-approve Alimta (J9305).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on July 7, 2020.
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says there is no authorization for this service and the enrollee was custodial on this date of 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 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 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 subsequent nursing facility care provided on July 7, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of HHA services.

You asked the Plan to pre-approve continuation of HHA services. You say that continuation of HHA services is medically necessary. The Plan denied your request. The Plan says continuation of HHA services is not medically necessary.

The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy.

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 continuation of HHA services. Our
reviewer says that HHA services are not medically necessary. Our physician reviewer found that the
documentation does not support that the enrollee requires skilled nursing services or skilled rehabilitation
services to provide treatment that is medically necessary. The enrollee does not require skilled nursing or
rehabilitation services to effectively provide treatment, care, and/or services in order to improve the enrollee's
condition, perform a maintenance program to maintain the enrollee's condition and/or prevent
deterioration. The enrollee has been medically stable without any recent exacerbations of chronic medical
problems or hospitalizations. There is no need for skilled care therefore the requested home health aide is not
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 continuation of HHA services have not been met. Therefore, we decided that
the Plan does not have to pre-approve continuation of HHA services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee meets the criteria for admission. The Plan denied your request. The Plan says the enrollee's needs can be met in a lower level of care.
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 patient does not require treatment by multiple therapies and an intensive rehabilitation therapy program. While the patient does require physical and occupational therapy, there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. 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 inpatient rehabilitation facility (IRF) admission and services.