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

We decided that the Plan does not have to waive the coinsurance for the out-of-network services provided from February 6, 2019 through August 21, 2019.You asked the Plan to waive the coinsurance for the out-of-network services. You say that you were referred there by your in-network provider. You say that you should be exempt from the out-of-network costs.The Plan denied your request. The Plan says the out-of-network coinsurance applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for each Medicare-covered hospital stay until discharge, 20% coinsurance for services other than outpatient hospital procedures or surgery and 20% coinsurance for each Medicare-covered outpatient surgery or procedure at an outpatient hospital facility or ambulatory surgical center. You have been asked to pay a total of $8,637.17, which is 20% of the allowed amount for the out-of-network services. The allowed amount is $43,186.17 (20% x $43,186.17 = $8,637.17). The out-of-network services fall within the "Inpatient hospital care" "Outpatient hospital services" and "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show that the provider is out-of-network, therefore the out-of-network coinsurance applies. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the coinsurance for the out-of-network services provided from February 6, 2019 through August 21, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve face masks (E1399).
You asked the Plan to pre-approve face masks. You say that you have a compromised immune system and would like assistance in obtaining face masks due to COVID 19. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve face masks (E1399).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve four additional home health occupational therapy visits (G0152).You asked the Plan to pre-approve four additional home health occupational therapy visits. You say that continued therapy is necessary.The Plan denied your request. The Plan says the enrollee can now perform a home exercise program on her own.The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.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 four additional home health occupational therapy visits. Our reviewer says that the requested services are not medically necessary. Our physician reviewer found based on the medical records provided the records do not show that the four additional skilled occupational therapy services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's level of function, or to establish/perform a maintenance program to maintain the patient's level of function or prevent 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 four additional home health occupational therapy visits have not been met.Therefore, we decided that the Plan does not have to pre-approve four additional home health occupational therapy visits (G0152).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forcontinuous intraoperative neurophysiology monitoring from outside the operating room (CPT Code 95941) provided to the enrollee on July 1, 2019.You asked the Plan to pay forthe service. You say that the service is medically necessary.The Plan denied your request. The Plan says the Medicare rules have not been met.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the service have not been met. Continuous intraoperative neurophysiology monitoring from outside the operation room (remote or nearby) or for monitoring of more than one case while in the operating room (CPT code 95941)is not payable by Medicare. The enrollee was inpatient when they received the services.Therefore, we decided that the Plan does not have to pay forcontinuous intraoperative neurophysiology monitoring from outside the operating room (CPT Code 95941) provided to the enrollee on July 1, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe inpatient hospital care provided to the enrollee from November 8, 2019 to January 13, 2020.You asked the Plan to waive the copayment forthe inpatient hospital care. You say that  The Plan denied your request. The Plan says thatthe 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $325 copayment per day, for days 1 to 5 of Inpatient hospital care. The enrollee has been asked to pay a $1,625 copayment for the inpatient hospital care. The inpatient hospital care falls within the days 1 to 5 of Inpatient hospital care 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 thePlan does not have to waive the copayment forthe inpatient hospital care provided to the enrollee from November 8, 2019 to January 13, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 18 additional physical therapy visits.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are 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 these services. 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 the enrollee has chronic neck and mid-back pain. He has had 12 prior therapy visits and the documentation does not reveal evidence of significant objective functional improvement that would indicate additional therapy would be effective. The requested therapy is generally not accepted as specific and effective therapy for his condition. The documentation does not support that he needs the unique skills of a professional therapist to safely and effectively provide treatment. The requested services are not part of a maintenance program and the specialized skill, knowledge and judgment of a qualified therapist is not 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve 18 additional physical therapy visits.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on December 30, 2019.
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 include a physician order/lab requisition or medical records stating exactly what tests are to be performed.
The Plan must follow Medicare rules. Medicare rules say that a physician order must be present for labs to be covered. The documentation submitted did not include a physician order/lab requisition or medical records stating exactly tests were to be performed. 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 drug testing services provided to the enrollee on December 30, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services for the enrollee.You asked the Plan to pre-approvethe LTACH services. You say that the enrollee needs care that can only be provided at an LTACH.The Plan denied your request. The Plan says that transfer to an LTACH would add no additional services.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. 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. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea podiatry consult to be provided by an out of network (OON) provider.You asked the Plan to pre-approvethese OON services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services can be provided by an in-network provider.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approvea podiatry consult to be provided by an out of network (OON) provider
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approve Repatha 140mg/ml SureClick for the enrollee.You asked the Planto pre-approvethe drug. You say that this request is fully consistent with both the FDA-approved indication and the current standards of care.The Plandenied your request. The PlansaysMedicare says Part B programs can only provide limited benefits for prescription drugs.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plandoes not haveto pre-approve Repatha 140mg/ml SureClick for the enrollee.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay formedical services provided to the enrollee on November 20, 2019.You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says this claim must be submitted to Original Medicare due to the enrollee's hospice status at the time of service.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay formedical services provided to the enrollee on November 20, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for hyperbaric oxygen under pressure, full body chamber, per 30 minute interval (G0277) provided to the enrollee on November 26, 2019.
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the service have not been met. The member was inpatient for the date of service. This service should be covered in the payment with the inpatient stay. Therefore, we decided that the Plan does not have to pay for hyperbaric oxygen under pressure, full body chamber, per 30 minute interval (G0277) provided to the enrollee on November 26, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee's medical condition at this time does not require being seen by a doctor three times a week or an intensive rehab team for their care.
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 records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a SNF level of care. Ongoing medication management, skin care, and daily therapy can be provided at a SNF. A less intensive, longer duration of therapy will allow for measurable gains to be attained within a predicted period. 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued CPAP and supply use for the enrollee.
You asked the Plan to pre-approve these services. You say that the enrollee needs this to sleep. The Plan denied
your request. The Plan says that there are no notes showing the enrollee's CPAP usage.
The Plan must follow Medicare rules. Medicare rules say that you must use the PAP 4 hours per night on 70%
of nights during a consecutive thirty (30) day period anytime during the first three (3) months of initial usage.
We looked at the file and Medicare rules. The file did not include any documentation or compliance report
indicating the enrollee is compliant with CPAP usage. 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-approve continued CPAP and supply use for the enrollee.
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 records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing medication management, skin care, and daily therapy can be provided at a SNF. In this case, the enrollee is mostly minimal assist for functional transfers and activities of daily living (ADL's) and a less intensive, longer duration of therapy will allow for measurable gains to be attained within a reasonable period. 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 long-term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says that the enrollee is receiving appropriate in-patient acute care.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. 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. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvenot otherwise classified, single vision lens (V2199) and frames, purchases (V2020).You asked the Plan to pre-approvethe routine eyewear. You say that you are requesting eyeglasses and frames to focus on the words when reading and for driving or watch TV for more than an hour and functioning day to day life.The Plan denied your request. The Plan says this item is not covered under Medicare or the Health Plan.The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. The services you asked the Plan to pre-approve are considered routine vision services or eyewear.Therefore, we decided that the Plan does not have to pre-approvenot otherwise classified, single vision lens (V2199) and frames, purchases (V2020).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for pneumatic compressor, segmental home model with
calibrated gradient pressure (E0652) provided to the enrollee on May 31, 2019.
You asked the Plan to pay for the DME. You say that the claim should be paid. The Plan denied your request.
The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the DME have not been met. In the home indications and
limitations of coverage: "Pneumatic devices are covered only for the treatment of lymphedema or for the
treatment of chronic venous insufficiency with venous stasis ulcers." Pneumatic compression devices are
covered in the home setting for the treatment of lymphedema or for the treatment of chronic venous
insufficiency with venous stasis ulcers, only if the patient has undergone a four-week trial of conservative
therapy and the treating physician determines that there has been no significant improvement or if significant
symptoms remain after the trial. The trial of conservative therapy must include use of an appropriate
compression bandage system or compression garment, exercise, and elevation of the limb. The garment may be
prefabricated or custom-fabricated but must provide adequate graduated compression. No trial of conservative
care was documented. A non-covered service, is not a benefit when ordered by either a contracted or a noncontracted
provider. Therefore, we decided that the Plan does not have to pay for pneumatic compressor,
segmental home model with calibrated gradient pressure (E0652) provided to the enrollee on May 31, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to approve physician services to be provided by the facility.
You asked the Plan to approve physician services physician services. You say that you would like this claim approved. The Plan denied your request. The Plan says that there are in-network providers available.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. You were referred for physician services by a contract provider. You were referred for these by your primary care physician. Under Medicare rules, this means physician services is considered approved by the Plan. Therefore, we decided that the Plan has to approve physician services to be provided by the facility.
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.