Persius/hicric huggingface dataset:
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 this level of care would be best for the enrollee. The Plan denied your request. The Plan says you are receiving adequate care in the current facility and do not require any services that can only be provided at an LTACH.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is a 59-year-old man with multiple medical problems for whom admission to a long-term acute care hospital (LTACH) has been requested. The enrollee was admitted to the acute care hospital from an LTACH on 6/25/20 for a second opinion regarding a diverting colostomy and placement of a PEG tube. The colostomy and PEG tube were placed on 6/30/20. The enrollee remains on a ventilator via tracheostomy. Bacteremia with Enterococcus faecalis was demonstrated in blood cultures on 7/7/20. Antibiotics are to be continued for 6 weeks. A CT scan was to be obtained to rule out a retroperitoneal bleed. Long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. The member is receiving acute hospital care, and acute care services have not been denied. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving 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 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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network provider on July 17, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, plans are not required to make payments for any services received by enrollees that are not provided directly by the Plan or through arrangements made by the Plan. The services at issue in this appeal were not provided in an emergency or urgent care situation. These services were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network provider on July 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services you received on December 2, 2019.
You asked the Plan to pay for the services. 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 $5 copayment for each PCP visit. Your contract also says that the plan covers two counseling quit attempts per 12-month period. Review of the file shows that you had a PCP visit and smoking cessation counseling on December 2, 2019. You have been asked to pay a $5 copayment for the PCP visit. The visit falls within the physician 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. Additionally, the records show that you received eight counseling quit attempts in 2019. This exceeds the benefit limit, which means that the requested smoking cessation counseling is not covered. Therefore, we decided that the Plan does not have to pay for the services you received on December 2, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for a psychotherapy visit provided on January 2, 2020.
You asked the Plan to pay for office visit. You say that this provider did not help you with your situation. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is not eligible to participate in Medicare or receive payment for Medicare-covered services.
The Plan must follow Medicare rules. Medicare rules say that a Licensed Professional Counselor is not eligible to participate in Medicare and is not covered. We looked at the file and Medicare rules. The rendering provider is not covered by Medicare and therefore cannot be paid for service. Based on this information, we decided that Medicare rules for coverage of office visit have not been met. Therefore, we decided that the Plan does not have to pay for a psychotherapy visit provided on January 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on October 17, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 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 medical services provided to the enrollee by an out-of-network provider on October 17, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the physical therapy visits provided from January 30, 2020 to March 11, 2020.
You asked the Plan to waive the copayments for the physical therapy visits. You say that you were told the physical therapy visits would be covered. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for each in-network Medicare-covered visit. You have been asked to pay a total of $230.83 for the physical therapy visits. The physical therapy visits fall within the "Outpatient rehabilitation services" benefit category. See chart below.
Date of Service
Service
Allowed Amount
Copayment
Member Liability
January 30, 2020
Physical Therapy
$106.79
$40
$40.00
February 4, 2020
Physical Therapy
$35.96
$40
$35.96
February 11, 2020
Physical Therapy
$38.82
$40
$38.82
February 18, 2020
Physical Therapy
$38.41
$40
$38.41
February 27, 2020
Physical Therapy
$38.82
$40
$38.82
March 11, 2020
Physical Therapy
$38.82
$40
$38.82
Total
$230.83
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 physical therapy visits provided from January 30, 2020 to March 11, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the skin lesion removal procedure provided on March 5, 2020.
You asked the Plan to waive the copayment for the skin lesion removal procedure. You say that you do not feel that an office copayment should not apply to a follow-up visit. 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 $10 copayment for each in-network primary care provider visit for Medicare-covered services. You have been asked to pay a $10 copayment for the skin lesion removal procedure. The skin lesion removal procedure falls within the "Physician/Practitioner services, including office visits" benefit category. Please note, there is no provision in the contract which indicates a copayment would be waived if performed as a follow-up visit.
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 skin lesion removal procedure provided on March 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for psychiatry services provided on December 5, 2019.
You asked the Plan to pay for psychiatry services. You say that you believe you are in-network with the Plan. The Plan denied your request. The Plan says the denial of payment for these services is correct, because no documentation was submitted to show how the enrollee came to this provider or whether the services were medically necessary.
The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the Plan sufficient information to determine whether payment is due for a claim. We looked at the file and Medicare rules. No documentation was submitted to the Plan to support the services billed. The Plan requested supporting documentation but it was not provided. Without supporting records, you have not furnished to the Plan sufficient information to justify payment of the claim as billed. Based on this information, we decided that Medicare rules for coverage of psychiatry services have not been met. Therefore, we decided that the Plan does not have to pay for psychiatry services provided on December 5, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the arthrocentesis provided on January 22, 2020.
You asked the Plan to waive the copayment for the arthrocentesis. You say that the charge reflects that you had outpatient surgery. You say that you already paid your $45 copayment. The Plan denied your request. The Plan says the copayment 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 $225 for each in-network, Medicare-covered outpatient hospital facility visit. You have been asked to pay a $225 copayment for the arthrocentesis. The arthrocentesis falls within the "Outpatient surgery including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The arthrocentesis is considered a surgical procedure that was also billed by the hospital. 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 arthrocentesis provided on January 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nurse practitioner services provided on February 3, 2020.
You asked the Plan to pay for the nurse practitioner services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 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 nurse practitioner services provided on February 3, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the EKG provided on October 23, 2019.
You asked the Plan to pay for the EKG. The Plan denied your request. The Plan says this was billed in error.
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. We looked at the file and Medicare rules. The records show that one EKG was paid for by the plan for the date of service in question. The second EKG was billed in error as a duplicate claim line. Based on this information, we decided that Medicare rules for coverage of the EKG have not been met. Therefore, we decided that the Plan does not have to pay for the EKG provided on October 23, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for prophylaxis - adult (D1110), bitewings - four radiographic images (D0274) and periodic oral evaluation - established patient (D0120) provided on February 4, 2020 by an out-of-network provider.
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC benefits.
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. Review of the file show that you received prophylaxis - adult (D1110), bitewings - four radiographic images (D0274) and periodic oral evaluation - established patient (D0120) on February 4, 2020 from an out-of-network provider. For code D1110, the provider billed the plan $98.00. The allowed amount for the service is $47.00, and the plan paid $47.00. You are responsible for all fees in excess of the allowed amount, $51.00 ($98 - $47). For code D0274, the provider billed the plan $68.00. The allowed amount for the service is $30.00, and the plan paid $30.00. You are responsible for all fees in excess of the allowed amount, $38.00 ($68 - $30). For code D0120, the provider billed the plan $54.00. The allowed amount for the service is $22.00, and the plan paid $22.00. You are responsible for all fees in excess of the allowed amount, $32.00 ($54 - $22). The $121.00 which was assessed as your out-of-network liability is correct. Your EOC states, Providers are paid based on Maximum Allowable Charge (MAC). For services covered under the plan, you may still be billed by an out-of-network provider for any amount greater than the MAC payment made by the plan to the provider. Therefore, we decided that the Plan does not have to pay for prophylaxis - adult (D1110), bitewings - four radiographic images (D0274) and periodic oral evaluation - established patient (D0120) provided on February 4, 2020 by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve use of Xofigo (Radium-223 Dichloride).
You asked the Plan to pre-approve Xofigo. You say that Xofigo is indicated at this point in the treatment of the enrollee's cancer. The Plan denied your request. The Plan says that the denial of authorization for Xofigo is correct, because the records submitted do not include details such as a recent consultation with the treating physician, number and type of treatments needed, results of testing related to treatment, and the stage of the enrollee's cancer.
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 Xofigo. Our reviewer says that the enrollee meets the Medicare criteria for the requested use of Xofigo. Our physician reviewer found Xofigo is Food & Drug Administration (FDA) approved for the treatment of symptomatic bone metastasis in patients with hormone-refractory prostate cancer. The documentation supports that Xofigo is expected to be safe and effective, and otherwise reasonable and necessary for the enrollee 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 Xofigo have been met. Therefore, we decided that the Plan has to pre-approve use of Xofigo (Radium-223 Dichloride).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided from December 6, 2019 to December 20, 2019.You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says the enrolleemust 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 servicesat 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 psychotherapy services providedfrom December 6, 2019 to December 20, 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 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 you do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The submitted records document a need for physical and occupational therapy services but do not document a need for an intensive rehabilitation program. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on October 10, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.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 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 medical services provided to the enrollee by an out-of-network provider on October 10, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on January 14, 2020.
You asked the Plan to pay for the dental services. You say that you would like the limit allowance be increased to the maximum coverage of $3,000. The Plan denied your request. The Plan says you exhausted your maximum benefit allowance.
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. You exhausted your $1,500 maximum benefit allowance. Your EOC states, in-network and out-of-network there is a $1,500 combined allowance for supplemental preventive and comprehensive dental services every year. Member is responsible for any amount over and above the allowance amount. Therefore, you are asked to pay any amount over and above the allowance amount. Therefore, we decided that the Plan does not have to pay for the dental services provided on January 14, 2020.