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

We decided that the Plan does not have to waive the cost share for the therapeutic radiology services and the specialist visits provided from December 11, 2019 to December 31, 2019. 
 
You asked the Plan to waive the cost share for the therapeutic radiology services and the specialist visits. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received therapeutic radiology and specialist visits on the dates of service at issue in this appeal. The Plan says that the correct cost share has applied per your contract with the Plan. 
 
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 20% coinsurance for therapeutic radiology and a $50 copayment for specialist visits.  
 
We looked at the file, the Plan contract and Medicare rules. The file shows that you received therapeutic radiology services and specialist visits from December 11, 2019 to December 31, 2019. You have been asked to pay a 20% coinsurance for each therapeutic radiology service. Therapeutic radiology falls within the Outpatient diagnostic tests benefit category. The file shows you received services provided by a specialist. You have been asked to a $50 copayment for the specialist visit on December 11, 2019 and a $15 copayment, which is less than the contracted $50 copayment amount for the specialist visit on December 17, 2019. The specialist services fall within the Physician/Practitioner services benefit category. This means that you have been asked to pay the correct amounts 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 cost share for the therapeutic radiology services and the specialist visits provided from December 11, 2019 to December 31, 2019.
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 IRF admission is medically necessary.The Plan denied your request. The Plan says your needs can be met at 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 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 you do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met at a lower 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on February 12, 2020. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says 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. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the laboratory services. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for laboratory services provided on February 12, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on February 5, 2020.You asked the Plan to waive the copayment for the emergency room visit. You say that you are unable to pay the $90 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 $90 copayment for Medicare-covered emergency room visits. You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls within the "Emergency care" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the emergency room visit provided on February 5, 2020.Your complaint about your pain and suffering is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve lumbar decompression procedure.You asked the Plan to pre-approve lumbar decompression procedure. You say that you would like the plan to reconsider their denial The Plan denied your request. The Plan says that the requested services are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 pre-approve lumbar decompression procedure. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewerfound the enrollee presents with chronic low back pain radiating into the left lower extremity. The enrollee reports worsening symptoms over the last few months, worse with activities. Signs/symptoms are consistent with neurogenic claudication. Clinical exam findings have documented sensory deficit consistent with moderate central and lateral recess stenosis at the L3/4 level. The enrollee has failed to improve despite long-term conservative treatment, including activity modification, medications, and ambulatory assist device. Evidence based medical literature would support proceeding with decompression surgery to assess this enrollee's significantly symptomatic spinal stenosis. The enrollee has declined injection therapy. This enrollee has a diagnosis, condition and symptoms that meet the Medicare criteria for coverage of lumbar decompression surgery. Therefore, lumbar decompression surgery would be considered the standard of care for the treatment of this enrollee's condition, and it would be considered medically reasonable and necessary for him to have lumbar decompression surgery.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of lumbar decompression procedure have been met.Therefore, we decided that the Plan has to pre-approvelumbar decompression procedure.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 ifthere 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing rendered on March 11, 2020.You asked the Plan to pay for these services. You say that you disagree with the denial.The Plan denied your request. The Plan says the claim was not billed correctly.The Plan must follow Medicare rules. The rules say that the Guardant360 panel must be billed with procedure code 81479.The file shows that the Guardant360 panel was not billed with code 81479 but as a panel of codes. 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 Guardant360 testing rendered on March 11, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forlab services provided on January 14, 2020 by an out of network (OON) provider.You asked the Plan to pay forlab services. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the member's primary care physician did not refer 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 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 forlab services provided on January 14, 2020 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve SNF care. You say that an inpatient skilled nursing facility admission is medically necessary. The Plan denied your request. The Plan says you do not meet criteria for coverage of an inpatient skilled nursing facility admission. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that an inpatient skilled nursing facility admission is not medically necessary. Our physician reviewer found that you do not require skilled nursing or skilled therapy services on a daily basis. Additionally, you do not require the services on an inpatient basis, in a skilled nursing facility setting. Services in the long-term care facility on a part time basis appears appropriate 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve an inpatient skilled nursing facility (SNF) admission.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that an inpatient rehabilitation facility admission is medically necessary. The Plan denied your request. The Plan says you do not meet criteria for coverage of an inpatient rehabilitation facility admission. 
 
The Plan must follow Medicare rules. The rules say that an 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 the complexity of your nursing, medical, and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do require physical and occupational therapy, but you do not require an intensive inpatient rehabilitation therapy program. Additionally, there is concern that you will not be able to fully participate in and benefit from an intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. You do not appear to be stable to be discharged from the hospital to an acute inpatient rehabilitation facility. 
 
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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services provided on February 19, 2019.You asked the Plan to pay for the laboratory 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 are not covered.The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, however, 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. We find that payment for the lab services is not supported in the medical record. We find that the issue of intent is not clear. There are no medical records in the case file in regards to the physician's intent that the test be performed prior to services taking place.Therefore, we decided that the Plan does not have to pay forthe laboratory services provided on February 19, 2019
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on February 3, 2020. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.  
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the laboratory services. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for laboratory services provided on February 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital care (99232) and medication (J8499) provided by a Veterans Administration (VA) facility from January 2, 2020 to January 6, 2020. 
 
You asked the Plan to pay for hospital care and medication. You say that you did not have a choice about the facility. The Plan denied your request. The Plan says payment cannot be made for services provided by a VA. 
 
The Plan must follow Medicare rules. Medicare rules say that payment may not be made for items and services furnished by a provider of services or agency of the Federal government. 
 
We looked at the file and Medicare rules. The record shows that the services at issue were provided at a VA facility, which is a provider of services or agency of the Federal government. Based on this information, we decided that Medicare rules for coverage of hospital care and medication have not been met. Therefore, we decided that the Plan does not have to pay for hospital care (99232) and medication (J8499) provided by a Veterans Administration (VA) facility from January 2, 2020 to January 6, 2020.
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not 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 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 preapprove 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, the enrollee does not require 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. Medicare coverage criteria are not met. 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 for the enrollee
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for SPECT (78451) provided on November 26, 2019. 
 
You asked the Plan to waive the coinsurance for the SPECT. You say that you would like reconsideration because you were not aware that the coinsurance for this service would be so high. The Plan denied your request. The Plan says the cost share applied correctly per the 2019 EOC. 
 
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 30% coinsurance for out-of-network Medicare-covered non-radiological diagnostic services. 
 
Please note, the Plan has covered these out-of-network services at an in-network benefit level. The Plan contract says that you are responsible for a 20% coinsurance for in-network Medicare-covered non-radiological diagnostic services. 
 
You have been asked to pay $298.17. The allowed amount for this service is $1,490.87. 20% of $1,490.87 is $298.17. 
 
You have been asked to pay $298.17 for the SPECT. SPECT falls within the out-of-network Medicare-covered non-radiological diagnostic services. benefit category. This means that you have been asked to pay less than the contracted 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 SPECT (78451) provided on November 26, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing home services (G0299x6) physical therapy home services (G0151x6) and occupational therapy home services (G0152x6)You asked the Plan to pre-approve the nursing and therapy home visits. You say that you are requesting reconsideration of the denied services because you really need the services.The Plan denied your request. The Plan says the requested services have been found to be not medically necessary.The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.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 nursing and therapy home visits. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found after careful review, the enrollee received oral medications. She used
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a lumbar spine MRI.You asked the Plan to pre-approve a lumbar spine MRI. You say that the requested lumbar spine MRI is medically necessary.The Plan denied your request. The Plan says that the requested lumbar spine MRI is not medically necessary.The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 pre-approve a lumbar spine MRI. Our reviewer says that the requested lumbar spine MRI is medically necessary. Our physician reviewer found this enrollee presents with complaints of persistent upper and lower back pain status post a traumatic fall on 6/9/20. She is reporting worsening symptoms including weakness. Comorbidities include Charcot-Marie-Tooth. Clinical exam findings have documented left lower extremity motor deficits and reflex changes. There is imaging evidence of T12 compression fracture, possibly chronic, and degenerative disc disease. Initial conservative treatment has included activity modification, medications, and physical therapy. Under consideration is a request for a lumbar spine MRI. A thoracic MRI has been approved to assess the age of the compression fracture. Given the history of trauma and worsening symptoms, including unilateral weakness and patellar reflex changes, proceeding with a lumbar spine MRI for differential diagnosis and treatment planning is indicated. Therefore, this request for lumbar spine MRI is 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 a lumbar spine MRI have been met.Therefore, we decided that the Plan has to pre-approve a lumbar spine MRI.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.