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

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that short term rehabilitation at the requested facility is medically necessary. The Plan denied your request. The Plan says SNF care is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee is ambulating more than 100 feet and tending to activities of daily living (ADL) with minimal supervision. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs at this point are custodial and, as a practical matter, can be provided at a lower level of care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis (HCPCS L1833 and HCPCS L2397) provided to the enrollee on January 21, 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 documentation submitted did not indicate the provider discussed the need for the billed supply code; therefore the billed supply code cannot be verified.
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 L1833: Knee orthosis, adjustable knee joints (unicentric or polycentric), positional orthosis, rigid support, prefabricated, off-the shelf HCPCS L2397: Addition to lower extremity orthosis, suspension sleeve 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 no medical records have been submitted for review. Therefore, there is no documentation to support that the provided orthoses were medically necessary or reasonable. 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 a knee orthosis (HCPCS L1833 and HCPCS L2397) provided to the enrollee on January 21, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the AGILE patency capsule and wireless capsule
endoscopy for the enrollee.
You asked the Plan to pre-approve the procedure. You say that the enrollee is having pain in the mid-abdomen
with a known hernia. The Plan denied your request. The Plan says the requested service is considered
investigational.
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 procedure. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the available records do not support that a recent EGD and colonoscopy failed to show the
source of Appellant's symptoms, as prerequisite to performance of wireless capsule endoscopy. Further, Agile
capsule is not medically necessary in lieu of small bowel series to ensure small bowel patency.
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 procedure have not been met. Therefore, we decided that the Plan does not
have to pre-approve the AGILE patency capsule and wireless capsule endoscopy for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic radiology services provided on February 19, 2020.
You asked the Plan to pay for the diagnostic radiology services. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 diagnostic radiology services provided on February 19, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy provided on February 10, 2020.
You asked the Plan to waive the copayment for the colonoscopy. You say that the doctor informed you everything was ok except for some polyps. You say that there was no reason for the diagnostic colonoscopy. 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 a $450 copayment per visit for outpatient surgery. You have been asked to pay a $450 copayment for the colonoscopy. The colonoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show that polyps were removed during the colonoscopy, which is considered a surgical procedure. 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 colonoscopy provided on February 10, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on February 18, 2020.
You asked the Plan to pay for lab tests. You say that you are appealing with lab report results. The Plan denied your request. The Plan says the denial of payment for these services is correct, because these tests are not a covered benefit and 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 rules say that a physician order or clear intent to order specific lab services is required for covered lab services.
There is no documentation in the record of a specific concern for which this testing was ordered. These tests are not covered by Medicare for screening purposes. In addition, the documentation submitted does not include a valid physician order or clear intent to order the specific lab services billed on this claim. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on February 18, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory work provided on March 24,
2020.
You asked the Plan to waive the copayment for the laboratory work. You say that you were under the
impression that the copayment would be waived due to the Coronavirus. You say you could not leave your
home and the blood work collected by the Mobile Unit was processed at a hospital. 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 $30
copayment for Medicare-covered lab services and diagnostic procedures/tests performed in a physician's office.
You have been asked to pay a $30 copayment for the laboratory work. The laboratory work falls within the
"Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows you
were billed by the outpatient hospital for the laboratory work.
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 laboratory work provided on March 24, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe emergency room visit provided on October 28, 2019.You asked thePlan to waive the copayment forthe emergency room visit. You say that you should not be responsible for the copayment. You say the doctor only spent two minutes with you. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 copayment for each emergency room visit. You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls within the "Emergency care" benefit category. The record shows you received services during your emergency 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 forthe emergency room visit provided on October 28, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on February 17, 2020.You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.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 payfor 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 providerwith the Plan. The Plandid not pre-approve the laboratory services. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for laboratory services provided on February 17, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that you require these services.The Plan denied your request. The Plan says you do not meet coverage criteria based on Medicare guidelines.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 medically stable and there is no evidence of complex medical issues that require monitoring by an inpatient rehabilitation physician three times per week or acute rehab nursing care. While you have expected benefit from continuing therapy there is no apparent need for an intensive therapy program with therapy three hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation 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-approvelong term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve a second and third level cervical/thoracic facet injection for the
enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your
request. The Plan says that the enrollee reported little to no relief from the previous injection.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item
or service, then that item or service will be covered when it is medically necessary.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the injection. Our reviewer says that the
requested injection is considered medically reasonable and necessary in this case. Our physician reviewer
found this is the first set of diagnostic MBBs at a different level than the prior facet blocks. The request is
medically reasonable and necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the injection have been met. Therefore, we decided that the Plan has to preapprove
a second and third level cervical/thoracic facet injection for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the inpatient hospital stay provided from
March 9, 2020 to March 16, 2020.
You asked the Plan to reduce the copayment for the inpatient hospital stay. You say that you should have been
discharged on March 13, 2020. You say you should only be responsible for a $1,000 copayment. The Plan
denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275
copayment per day for days 1-6 and a $0 copayment per day for additional days.
You have been asked to pay a $275 copayment for each day, for days 1 to 6 of the inpatient hospital stay. ($275
x 6 = $1,650). The inpatient hospital stay falls within the "Inpatient hospital care" benefit category. The
medical record shows you were stable for transfer to rehabilitation on March 16, 2020.
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 reduce the copayment for the inpatient hospital stay provided from March 9, 2020 to
March 16, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary for the
enrollee. The Plan denied your request. The Plan says that hospital records show that the enrollee's medical
conditions have improved and she can safely receive her care in a less intensive setting.
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. The
enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to
require fifteen hours per week of rehabilitative services, to be able to perform fifteen hours per week of
rehabilitative services or to require regular physician evaluation. The enrollee's care needs can be met at a
lower level of care. Our physician reviewer found that the enrollee's 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 for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of interlaminar/interspinous process
stabilization/distraction device (22867).
You asked the Plan to pre-approve the insertion of interlaminar/interspinous process stabilization/distraction
device. You say that this is covered by Medicare. The Plan denied your request. The Plan says this is
experimental.
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 insertion of
interlaminar/interspinous process stabilization/distraction device. Our reviewer says that the requested services
are not considered medically reasonable and necessary in this case. Our physician reviewer found the spacer
device is experimental. More research is needed to show it is safe and effective.
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 insertion of interlaminar/interspinous process stabilization/distraction device
have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of
interlaminar/interspinous process stabilization/distraction device (22867).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 30, 2019 by an
out of network (OON) provider.
You asked the Plan to pay for laboratory testing. You say that you are an independent laboratory that relies on
the referring physician to obtain authorization. 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 the ordering
provider is also out-of-network with 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 has network providers
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the medical services provided on December 30,
2019 by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ER visit provided from March 13, 2020 through March 15, 2020.You asked the Plan to waive the copayment forthe ER visit. You say that you shouldn't have been forced to go to the hospital. You say that you shouldn't be liable.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 a $90 copayment per emergency room visit within or outside the service area.You have been asked to pay a $90 copayment for the ER visit. The ER visit falls within the "Emergency care" benefit category. The records show that you were treated in the ER. This means that you have been asked to pay the correct amount based on your contract withthe 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 forthe ER visit provided from March 13, 2020 through March 15, 2020. Your complaint about fraudulent services 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: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from October 25, 2019 through October 27, 2019 and the ER visit provided on November 15, 2019.
You asked the Plan to waive the copayment for the inpatient stay and ER visit. You say that the bills are causing financial stress. The Plan denied your request. The Plan says the copayments 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 $320 copayment each day for days 1 to 5 for Medicare-covered hospital care and a $90 copayment for each emergency room visit. You have been asked to pay a total of $730 for the inpatient stay and ER visit.
Date of Service
Service
Standard Copayment
Member Liability
October 25, 2019-October 27, 2019
Inpatient Stay
$320/day
$640
November 15, 2019
ER Visit
$90
$90
TOTAL:
$730
The inpatient stay falls within the "Inpatient Hospital Care" benefit category. The ER visit falls within the "Emergency Care" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient stay provided from October 25, 2019 through October 27, 2019 and the ER visit provided on November 15, 2019.