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

We decided that the Plan does not have to pre-approvehallux rigidus correction with cheilectomy, debridement and capsular release of the first metatarsophalangeal joint; with implant (28291) and correction, hallux valgus (bunionectomy), with sesamoidectomy, when performed; with distal metatarsal osteotomy, any method (28296).You asked the Plan to pre-approvethese services. You say that you have a bone spur and can barely wear any shoes.The Plan denied your request. The Plan says that to have this request approved your healthcare provider should submit records showing clinical documentation of trial and failure of conservative treatment.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 ifthe Plan was correct in denying the request to pre-approve these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. You presented with a complaint of 1st metatarsophalangeal joint pain resulting in a consideration for the requested surgery. In order for the surgery to be considered appropriate, the guideline indicates that there must be a trial and failure of conservative non-operative treatments. There is no detailed evidence that you have trialed any conservative treatment prior to this request. The request was denied because there was no evidence of comprehensive/reasonable conservative treatment having been provided. The provider submitted no additional documentation to address theinitial rationale for the denial. Our physician reviewer found that your condition does not meet criteria for coverage of these 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approvehallux rigidus correction with cheilectomy, debridement and capsular release of the first metatarsophalangeal joint; with implant (28291) and correction, hallux valgus (bunionectomy), with sesamoidectomy, when performed; with distal metatarsal osteotomy, any method (28296).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 17, 2020 by an out of network (OON) provider.
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 services were rendered by an out-of-network provider without prior authorization.
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 September 17, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora Zoster (Shingles) vaccine.You asked the Plan to pay forimmunization. You say that you went to an in-network provider and other immunizations were covered, so you do not understand why this was not approved.The Plan denied your request. The Plan says the denial of payment for this immunization is correct, because this immunization is not covered by Medicare Part B and would instead be covered by Medicare Part D benefits.In the absence of injury or direct exposure to illness, Medicare does not pay for or provide immunization. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to immunization.Therefore, we decided that the Plan does not have to pay fora Zoster (Shingles) vaccine.Benefits for immunizationmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefitsand appeal rights.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from September 4, 2020, to September 12, 2020.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says Skilled Nursing Facility (SNF) care beyond 100 days per benefit period is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. The file shows that the enrollee received 100 days of SNF care during the benefit period from April 22, 2020, to September 3, 2020. The Plan has covered 100 days of SNF care. Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. the enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from September 4, 2020, to September 12, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the diagnostic colonoscopy provided on August 17, 2020.You asked the Plan to waive the cost share for the diagnostic colonoscopy. You say that you should not havea copayment for a screening colonoscopy. The Plan denied your request. The Plan says the colonoscopy turned into a diagnostic colonoscopy and you were charged the cost share 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 $425 deductible and a $100 copayment for Outpatient Hospital Service. You have been asked to pay $425 deductible and a $100 copayment for the diagnostic colonoscopy. The diagnostic colonoscopy falls within the Outpatient Hospital Service 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 cost share for the diagnostic colonoscopy provided on August 17, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe occlusal guard (D9944) provided on September 24, 2020.You asked the Plan to pay forthe occlusal guard. You say that this service is medically necessary.The Plan denied your request. The Plan says this is not a covered service under your supplemental benefit plan.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe occlusal guard (D9944) provided on September 24, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe oxygen concentrator filter rendered on September 9, 2020.You asked the Plan to waive the coinsurance forthese services. You say that you should not have to pay the coinsurance.The Plan denied your request. The Plan says the coinsurance was 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 a 10% coinsurance for durable medical equipment and related supplies. Review of the file shows that you received an oxygen concentrator filter on September 9, 2020. You have been asked to pay a 10% coinsurance for these services. These services fall within the durable medical equipment and related 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 coinsurance forthe oxygen concentrator filter rendered on September 9, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forhemoglobin (83036), thyroxine (84436), and thyroid stimulating hormone (84443) testing provided on August 26, 2020.You asked the Plan to pay forhemoglobin, thyroxine, and thyroid stimulating hormone testing. You say that these tests were medically necessary.The Plan denied your request. The Plan says these tests were performed for screening purposes.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.The test at issue in this appeal, hemoglobin, thyroxine, and thyroid stimulating hormone testing, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes.Therefore, we decided that the Plan does not have to pay forhemoglobin (83036), thyroxine (84436), and thyroid stimulating hormone (84443) testing provided on August 26, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 16, 2020 by an
out of network (OON) provider.
You asked the Plan to pay for mammography. You say that you are appealing with supporting records. The
Plan denied your request. The Plan says the denial of payment for these services 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 September 16,
2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora computed tomography (CT) scan of the thorax (71250) provided on August 24, 2020.You asked the Plan to waive the copayment fora CT scan of the thorax. You say that the service should be covered.The Plan denied your request. The Plan says the cost share was 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $200 copayment for each Medicare covered advanced radiology service for outpatient hospital services. The enrollee has been asked to pay a $200 copayment for each Medicare covered advanced radiology service for a CT scan of the thorax. This service falls within the outpatienthospital services benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan.Therefore, we decided that the Plan does not have to waive the copayment fora computed tomography (CT) scan of the thorax (71250) provided on August 24, 2020
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay forthe EEG (CPT 95816) provided on August 30, 2020.You asked the Plan to pay forthe EEG. The Plan denied your request. The Plan says that this is a column II code.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 says that CPT 95816 is not payable because it is a Column II code to Column I code 95720. However, a code pair search indicates that CPT 95720 is a Column II code and CPT 95816 is a Column I code. As CPT 95720 has been paid for this date of service, there is rule stating that the Column I code cannot be paid. The Plan has not provided documentation to substantiate its denial of CPT 95816.Therefore, we decided that the Plan has to pay forthe EEG (CPT 95816) provided on August 30, 2020.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the services are necessary. The Plan
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that 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 services available at the LTACH that the enrollee requires that are not
available at the health care setting being offered by the health plan. The requested LTACH services are not
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be
furnished safely and effectively only on an inpatient basis.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forplantar injections (64455) provided from July 20, 2020 to September 9, 2020.You asked the Plan to waive the copayment forplantar injections. You say that these services should be considered office visits.The Plan denied your request. The Plan says these services were outpatient hospital services.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 $400 copayment for outpatient hospital services. You have been asked to pay a $400 copayment or the lesser allowed amount for each plantar injection. Plantar injections fall within the outpatient hospital services benefit category. This means that you have been asked to pay the correct amountbased 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 forplantar injections (64455) provided from July 20, 2020 to September 9, 2020
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for long-term acute care hospital (LTACH) services provided on
March 26, 2020, through April 2, 2020.
You asked the Plan to pay for the LTACH services. You say that the services were medically necessary. The
Plan denied your request. The Plan says the enrollee's needs were being met in the acute care setting, and the
LTACH would not add additional services. Ongoing comfort care could have been provided in an alternative
setting such as at home with hospice services or in a skilled nursing facility.
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 pay for 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 that the enrollee did not require services at the LTACH that were not available at the acute care
hospital where they were currently receiving care. Consequently, the requested LTACH services were not
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at the time of
admission.
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. Specifically, the services could have
been received at a lower level of care. This means the LTACH was not reasonable or necessary. Therefore, we
decided that the Plan does not have to pay for long-term acute care hospital (LTACH) services provided on
March 26, 2020, through April 2, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that 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 the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's medical status does not require intensive physician or nursing supervision in an IRF. While the patient may benefit and participate in multiple therapies the enrollee's functional level does notrequire this on an intensive rehabilitation therapy program provided in an IRF. The enrollee is already ambulating 120 feet standby assist. Pain appears controlled. Her medical management is not complex.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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forchiropractic office visit (99202) provided August 10, 2020.You asked the Plan to pay forthe office visit. You say that you feel the $60 charge is bogus and they billed over a month late because you cancelled any further treatment after the third time because they weren't doing you any good.The Plan denied your request. The Plan says this service is not covered when rendered by a chiropractor.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine.Therefore, we decided that the Plan does not have to pay forchiropractic office visit (99202) provided August 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approveintraoral radiographic images (X-Ray) (D0230) provided on September 17, 2020.You asked the Plan to pre-approveintraoral X-Ray. You say that the services should be covered.The Plan denied your request. The Plan says the allowed maximum frequencyfor this service has been exhausted.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. Specifically, you received three intraoral X-Rays on September 17, 2020. The Plan covered one of the X-Rays per the Plan's maximumallowed frequency. This means you have exhausted the maximum frequency allowed for this service.Therefore, we decided that the Plan does not have to pre-approveintraoral radiographic images (X-Ray) (D0230) provided on September 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for domiciliary or rest home visit (99335) provided on August 24, 2020 by an out of network (OON) provider.

You asked the Plan to pay for domiciliary or rest home visit. You say that your physician provided medically necessary services to the enrollee in good faith. In consideration for the services rendered your doctor is seeking reimbursement. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for domiciliary or rest home visit (99335) provided on August 24, 2020 by an out of network (OON) provider.