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

We decided that the Plan has to waive the coinsurance for tissue transfer procedures provided on October 15, 2020.
You asked the Plan to waive the coinsurance for surgical services. You say that you should not have to pay this amount and should only have to pay the $20 copayment. The Plan denied your request. The Plan says that the coinsurance amount you are being charged is correct.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that enrollees must pay $20 copayment for specialist visit. The Plan says you must pay $260.38, which is 20% coinsurance for surgical services in addition to the $20 specialist copayment. Based on the Plan contract, however, you cannot be asked to pay more than $20 copayment for specialist services which you have already asked to pay and requested in your appeal. Therefore, we decided that the Plan has reduce the total cost-sharing for this claim from $280.38 to $20 copayment.
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 are appealing with supporting records. The Plan
denied your request. The Plan says the denial of authorization for IRF service is correct.
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 your nursing, medical, and rehabilitation needs does not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive
rehabilitation therapy program. Medically necessary care can be provided in a different level of care. 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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for observation care provided on October 11, 2020.
You asked the Plan to waive the coinsurance for observation care. You say that you were incorrectly diagnosed with a mental diagnosis. You say that you will not be paying for this. The Plan denied your request. The Plan says the coinsurance applied 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 40% for out-of-network provider and professional services. You have been asked to pay $42.13, which is 40% of the allowed amount for observation care. The allowed amount is $105.32 (40% x $105.32 = $42.13). Observation care 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 coinsurance for observation care provided on October 11, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 25, 2020 by an out of network (OON) provider.
You asked the Plan to pay for mammography. You say that you provided the enrollee with treatment in good faith and in turn ask for prompt payment of this claim. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and authorization 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 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 medical services provided on August 25, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH).
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says the services could be provided in another setting, such as an acute rehabilitation facility, skilled nursing facility, nursing facility, outpatient setting or home care.
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 you are currently undergoing treatment at an ACH for Fournier's gangrene. You received surgery and antibiotics. You continue to receive wound care. You are not intubated or ventilated. There is no evidence that you require services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. You can remain at the current ACH until such time no acute services are required. You can then be transferred/discharged to a lower level of care for any ongoing 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 admission to a long term acute care hospital (LTACH).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core build up (D2950) for tooth # 13.
You asked the Plan to pre-approve the dental service. You say that the enrollee needs this service. The Plan denied your request. The Plan says core build up is not listed as a covered service.
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-approve core build up (D2950) for tooth # 13.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for ophthalmology services provided on January 13, 2020 by an out of network (OON) provider.
You asked the Plan to pay for ophthalmology services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained for these services by a network provider.
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 ophthalmology services provided on January 13, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the implantation of the CardioMEMS device (33289).
You asked the Plan to pre-approve the implantation of the CardioMEMS device. You say that this service is
medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the clinical value
and effectiveness of the device in the setting of congestive heart failure has not been demonstrated.
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 implantation of the CardioMEMS
device. Our reviewer says that the requested items/services are not considered medically reasonable and
necessary in this case. Our physician reviewer found the efficacy of the CardioMEMS heart failure system
remains uncertain at this time. Further clinical study is needed to determine the efficacy and safety of this
device.
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 implantation of the CardioMEMS device have not been met. Therefore, we
decided that the Plan does not have to pre-approve the implantation of the CardioMEMS device (33289).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet blocks.
You asked the Plan to pre-approve destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint (64635) and destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint (64636). You say that the enrollee needs the facet blocks for pain relief. The Plan denied your request. The Plan says the records shows the enrollee did not have 80% or greater relief of pain after either of the two prior diagnostic Medial Branch Block procedures.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. The medical records only show a 62% and a 55% pain relief after the previous blocks. Based on this information, we decided that Medicare rules for coverage of destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint (64635) and destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint (64636) have not been met. Therefore, we decided that the Plan does not have to pre-approve facet blocks.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for portable x-ray services provided to the enrollee on October
12, 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 transportation and set up costs are subject to consolidated billing and are not separately
billable to Medicare Part B.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of the denied codes is:
HCPCS Q0092:
Set-up portable x-ray equipment
HCPCS R0070:
Transportation of portable x-ray equipment and personnel to home or nursing home, per trip to facility or
location, one patient seen
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the
services at issue in this case were not supported by the medical records. Our physician reviewer found the
services were not reported correctly according to Medicare guidelines. This claim does not meet criteria for
reimbursement consideration.
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 portable x-ray services provided to the enrollee on October 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical supplies to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the oral device (E0486). You say that you would like reconsideration because you were referred to this provider by your doctor. The Plan denied your request. The Plan says there are in-network providers who can supply this equipment.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the medical supplies to be provided by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Computed Tomography (CT) scan (71250) provided to your spouse on July 5, 2019.
You asked the Plan to waive the coinsurance for the CT scan. You say that your spouse had been deceased for 15 months at the time the recalculated bill was sent to you, and the estate was closed 9 months after his passing. You do not feel you should be responsible for this adjusted claim. The Plan denied your request. The Plan says the allowed amount for this service was found to be calculated in error initially. After the change in the allowed amount, the requested coinsurance was adjusted to reflect the required 20%.
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 20% coinsurance up to a maximum of $75 per day for diagnostic radiology services. You have been asked to pay coinsurance in the amount of $28.65 for the CT scan. The Plan's recalculated allowed amount for this service is $143.26 ($143.26 x 20% = $28.65). Originally, this claim was processed with an allowed amount of $136.44 and a $27.29 cost to you ($136.44 x 20% = $27.29). A CT scan falls within the diagnostic radiology 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 coinsurance for the Computed Tomography (CT) scan (71250) provided to your spouse on July 5, 2019.
Your complaint about the recalculation of this bill years after the service and your responsibility for payment as the estate 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a fluid-circulating cold pad with pump.
You asked the Plan to pre-approve the item. You say that not having this pump is causing a lot of swelling and
pain. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that a fluid circulating cold pad with pump (E0218) will be
denied as not reasonable and necessary.
The requested item is not considered medically reasonable or necessary by Medicare. Based on this
information, we decided that Medicare rules for coverage of the item have not been met. Therefore, we decided
that the Plan does not have to pre-approve a fluid-circulating cold pad with pump.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve whole exome sequence analysis.
You asked the Plan to pre-approve whole exome sequence analysis. You say that the requested testing is
medically necessary, as it is highly likely the enrollee has an inherited syndrome. The Plan denied your request.
The Plan says the requested testing is excluded from coverage under the Plan's Genetic and Molecular
Diagnostic Testing Policy.
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 whole exome sequence analysis. Our
reviewer says that whole exome sequence analysis is not considered medically reasonable and necessary in this
case. Our physician reviewer found it has not been established how the requested Whole Exome Sequencing is
expected to affect this enrollee's medical management and his outcome. There is no documentation of a
suspected medical condition that may be identified by whole exome sequence analysis, and thereby have an
impact on the enrollee's health.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of whole exome sequence analysis have not been met. Therefore, we decided that
the Plan does not have to pre-approve whole exome sequence analysis.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient hospital care for an approved shoulder surgery.
You asked the Plan to pre-approve inpatient services. The Plan denied your request. The Plan says there is no
expectation the enrollee will require greater than two midnight stays.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve inpatient services. Our physician
reviewer found that the enrollee is medically stable with a past medical history of osteoarthritis. She has been
experiencing pain in her shoulder, affecting activities of daily living. The Plan has approved shoulder surgery.
The procedure is currently approved as an ambulatory procedure. There is no documentation provided to
support the expectation that the has a condition that would require inpatient care for surgery. The record does
not show that the enrollee's necessary hospital care will span two midnights.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of inpatient services have not been met. Therefore, we decided that the Plan does
not have to pre-approve inpatient hospital care for an approved shoulder surgery.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for durable medical equipment provided on August 31, 2020, by
an OON provider.
You asked the Plan to pay for a wheelchair. You say that you would like this claim reprocessed and paid due to
medical necessity. The Plan denied your request. The Plan says the referring provider is out-of-network. The
Plan says that these services could have been provided in-network. The Plan says that prior authorization was
not obtained by a participating provider.
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 durable medical equipment provided on August
31, 2020, by an OON provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says this does not meet Medicare criteria, as needs are custodial. 
 
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 the admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found you do not require skilled nursing 
services with the specialized skill, knowledge and judgment of a skilled professional nurse required to safely 
and effectively provide medically necessary and reasonable treatment in a SNF. You have no complex wound 
care, IV medications or other SN need. Your functional level does not require skilled therapy services with the 
specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide 
medically necessary and reasonable treatment in a SNF. Skilled nursing or therapy services are not required on 
a "daily basis" or as a practical matter on 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).