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

We decided that the Plan does not have to waive the copayment for a specialist office visit provided by a participating provider on March 18, 2021.

You asked the Plan to waive the copayment for a specialist office visit. You say that you do not agree with this copayment. The Plan denied your request. The Plan says the correct copayment has been applied.

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 copayment for physician/practitioner services/specialist visit. 

You have been asked to pay a $30 copayment for a specialist office visit. The correct copayment has been applied to the services that were provided. A specialist office visit falls within the physician/practitioner services/specialist visit 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 a specialist office visit provided by a participating provider on March 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140), and the resin based
composite (D2335) provided on from March 9, 2021, to March 16, 2021.

You asked the Plan to pay for the dental services. You say that you were advised by a plan representative that
this plan covered dental services. The Plan denied your request. The Plan says limited oral evaluation is not
listed as a covered service. The Plan says that resin based composite is not listed as a covered service either.

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 limited oral evaluation and resin
based composite are not among those covered under this benefit. Additionally, the record shows that you were
not enrolled in the optional supplemental dental rider on the date of service in this case. Therefore, we decided
that the Plan does not have to pay for the limited oral evaluation (D0140), and the resin based composite
(D2335) provided on from March 9, 2021, to March 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing home visit (99336) and chronic care management (99490) provided on October 15, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the nursing home visit and chronic care management. You say that you would like reconsideration because it is the responsibility of the facility to obtain authorization. The Plan denied your request. The Plan says these services were not urgent, emergent or approved in advance.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The 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 nursing home visit (99336) and chronic care management (99490) provided on October 15, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient hospital laboratory services provided April 1, 2021.

You asked the Plan to waive the copayment for the outpatient hospital laboratory services. You say that you would like this copayment waived as previously you had not received this charge. The Plan denied your request. The Plan says the copayment has processed correctly in this case.

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 outpatient diagnostic tests and therapeutic services and supplies. 

You have been asked to pay a $40 copayment for the outpatient hospital laboratory services. These services fall within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the outpatient hospital laboratory services provided April 1, 2021.
Appeal type: ER
Decision: Favorable

We decided that the Plan has to pay for observation care provided to the enrollee from November 13, 2020, through November 19, 2020.

You asked the Plan to pay for the observation care. You say that the enrollee meets observation criteria and the visit was medically necessary. The Plan denied your request. The Plan says that the claim should be rebilled as inpatient status.

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 has not provided evidence or an explanation as to why this should be billed inpatient. Therefore, we decided that the Plan has to pay for observation care provided to the enrollee from November 13, 2020, through November 19, 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 an acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that this service is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an IRF 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 in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.

Our physician reviewer found that the complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for hydrocephalus. His medical conditions are stable. There are no complex nursing or rehabilitation needs. 

The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The patient does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. 

Additionally, there is not a reasonable expectation that this patient 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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that your needs can safely be met in an alternate setting such as a skilled nursing facility.

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. 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 were admitted for pelvic fractures after a fall.

Your medical conditions are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. You do require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services 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. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric hospitalization.

You asked the Plan to pre-approve inpatient psychiatric hospitalization. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 

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 psychiatric hospitalization. Our reviewer says that the service is not medically necessary. Our physician reviewer found it is not expected you would improve in a reasonable period of time beyond the dates in question as you are not showing any signs of danger to yourself or others, auditory or visual hallucinations, you are without aggressive behaviors and do not show any acute threats of safety. 

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 psychiatric hospitalization have not been met. Specifically, medically necessary services can be obtained at a lower level of care. This means this service is not medically necessary. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric hospitalization.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services provided on September 30, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the benefit limit has been exceeded.

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 $10 copayment per visit for up to 30 routine chiropractic visits per calendar year.

Review of the file shows that the enrollee was provided routine chiropractic services on September 30, 2020. The records show that the Plan had already paid for 30 routine chiropractic visits for 2020 prior to the services in question. This means that the requested visit exceeds the benefit limit and is not covered. Therefore, we decided that the Plan does not have to pay for the chiropractic services provided on September 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on December 11, 2020 by an out of
network provider.

You asked the Plan to pay for the office visit. You say that you did not obtain authorization, but the medical
records prove medical necessity. The Plan denied your request. The Plan says you did not request prior
authorization as required.

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 service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for the service. Therefore, we decided that the Plan does not have to pay for the office visit provided on December 11, 2020 by an out of network provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ten (10) additional PT visits.

You asked the Plan to pre-approve ten (10) additional PT visits. You say that additional PT is medically necessary. The Plan denied your request. The Plan says additional PT is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve ten (10) additional PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that the additional requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health Plan. The enrollee has had extensive prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. The enrollee has been instructed in and is compliant in a home exercise program. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ten (10) additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve ten (10) additional PT visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crowns (D2750), core buildups, including any pins when required (D2950), and endodontic therapy (D3310) provided on January 14, 2021, and February 15, 2021.

You asked the Plan to pay for the crowns, core buildups, and endodontic therapy. You say that the enrollee needed immediate care due to the severe infection. You also say that the enrollee had to go to an OON provider because there were no in-network providers available. The Plan denied your request. The Plan says these services were rendered by a non-participating provider. The Plan also says that the enrollee must use a participating dental provider.

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 for the crowns (D2750), core buildups, including any pins when required (D2950), and endodontic therapy (D3310) provided on January 14, 2021, and February 15, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on November 26, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no evidence of an established relationship between the member and the ordering physician.

The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a physician who has furnished a consultation or treats an enrollee for a specific medical problem.

The file does not contain documentation of an established relationship between the enrollee and the ordering provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on November 26, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on November 27, 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 had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided by an out-of-network provider on November 27, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment of a computed tomography (CT) scan of the chest (71250) provided on March 3, 2021.

You asked the Plan to waive the copayment of a CT scan of the chest. You say that you had a preventative low dose CT scan, but the provider submitted a claim for diagnostic radiology. The Plan denied your request. The Plan says the copayment you are being charged is correct.

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 $325 copayment per day, for outpatient diagnostic tests and therapeutic services and supplies.

You have been asked to pay a $107.49 copayment for a CT scan of the chest. The record shows the Medicare Allowed Amount is $107.49, which is lower than your copayment of $325 per the EOC. The records also show that the CT scan was rendered as a follow up to a pulmonary nodule, not for a standard lung screening. A CT scan of the chest falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment of a computed tomography (CT) scan of the chest (71250) provided on March 3, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient specimen collection rendered on January 5, 2021.

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 are not covered.

The Plan must follow Medicare rules. The rules say that laboratory tests not payable on the Clinical Diagnostic Laboratory Fee Schedule (CLFS) will be based on OPPS. 

We looked at the file and Medicare rules. The file shows that the claim was billed under OPPS and these services are not payable under this payment system. 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 outpatient specimen collection rendered on January 5, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient services provided on June 5, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the OON services. You say that the records support medical necessity. The Plan denied your request. The Plan says prior 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 file shows that the enrollee was seen for a follow up visit. The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the outpatient services provided on June 5, 2020 by an out of network (OON) provider.