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

We decided that the Plan does not have to pay for cholecystostomy tube placement (47490) provided on October 4, 2019.You asked the Plan to pay for the cholecystostomy tube placement. You say that you would like reconsideration based on the record submitted. The Plan denied your request. The Plan says the additional surgical service, 47490, was included as part of the global surgical package of the initial surgical procedure, 47490. The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for these procedures includes payment for the above listed services related to the surgery when furnished by the physician who performs the surgery. We find that CPT code 47490 is not supported in the record. Specifically, this service is bundled as part of the global surgical package for the initial surgical procedure. Based on this information, we decided that Medicare rules for coverage of the cholecystostomy tube placement have not been met. Therefore, we decided that the Plan does not have to pay for cholecystostomy tube placement (47490) provided on October 4, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the vision services provided on May 7, 2019 to May 16, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the vision services. You say that the enrollee has been going to this provider since 2004. He has been treating her eye condition for 15 years. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. The plan says that non-emergent services with non-contracted providers require prior-authorization prior to services being rendered.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan 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 vision services provided on May 7, 2019 to May 16, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveDoptelet Tab 20mg for the enrollee.You asked the Plan to pre-approveDopteletTab 20mg. You say that Doptelet Tab 20mg is medically necessary for the enrollee.The Plan denied your request. The Plan says Doptelet Tab 20mg is not covered under Medicare Part B.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 Plan does not have to pre-approveDoptelet Tab 20mg for the enrollee.Benefits for Doptelet Tab 20mgmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forinpatient hospital care from August 24, 2019 through August 26, 2019.You asked the Plan to waive the copayment forinpatient hospital care. You say that you are appealing your cost-share responsibility for the services you received.The Plan denied your request. The Plan says the claimwas processed accordingly with your 2019 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file shows that you received inpatient hospital care from August 24, 2019 through August 26, 2019. You were asked to pay a $300 copayment for inpatient hospital care. Per your contract, each time you are admitted to an acute care hospital, you pay $300. 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 forinpatient hospital care from August 24, 2019 through August 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean UpWalker (E0140).You asked the Plan to pre-approvethe UpWalker. You say that the longer you are unable to walk in an upright position the more damage you are causing your spine, shoulders and hips.The Plan denied your request. The Plan says you do not meet the rules for a walker with trunk support. 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 UpWalker. Our reviewer says that you do not need this medical item. Our physician reviewer found based on the medical records provided there is no indication that the UpWalker (E0140) is medically reasonable and necessary 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 the UpWalker have not been met.Therefore, we decided that the Plan does not have to pre-approvean UpWalker (E0140).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe colonoscopy provided on September 9, 2019.You asked the Plan to waive the copayment forthe colonoscopy. You say that the doctors was not out-of-network. You say that you are being charged out-of-pocket costs that you weren't expecting to pay.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 $255 copayment for surgery services at an in-network ambulatory surgical center.You have been asked to pay a $255 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 you were charged the in-network copayment. 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 colonoscopy provided on September 9, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.You asked the Plan to pre-approve the LTACH services. You say that the services are necessary.The Plan denied your request. The Plan says the care required can be provided in the current inpatient hospital setting.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 currently undergoing treatment at an acute care hospital (ACH) for chronic obstructive pulmonary disease (COPD) and acute respiratory distress syndrome (ARDS) in the setting of MS. The enrollee was intubated/ventilated and subsequently received a tracheotomy. The enrollee has since been weaned from the ventilator. It is unclear if decannulation is planned. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care (LTC) needs.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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) for enrollee.You asked the Plan to pre-approve these services. You say that the services are medically necessary.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that RFA is covered when specific criteria are met. 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 the services are not medically necessary. Our physician reviewer found the enrollee has chronic low backpain. She had an epidural steroid injection with minimal pain relief. She had a diagnostic medial branch block (MBB) that provided 100 percent pain relief, but the practitioner then states "40 percent overall." The progress note is not clear. The enrollee has not had a second MBB, as required by the Medicare criteria. There is no documented trial of physical therapy or conservative therapy. The RFA is therefore not reasonable or medically necessary at this time.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 radiofrequency ablation (RFA) for enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on October 11, 2019.You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says that in most cases, care you receive from an out-of-network provider will not be covered. If you need medical care that Medicare requires our plan to cover and the providers in our networkcannot provide this care, you can get this care from an out-of-network provider. You, or your PCP, must obtain authorization from the plan prior to seeking care.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 provided on October 11, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided August 20, 2019 to September 11, 2019
You asked the Plan to pay for the SNF services. You say that you feel that the plan should cover for the SNF services. The Plan denied your request. The Plan says the SNF benefits have been exhausted.
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. The file shows that you received 100 days of SNF care during the benefit period from March 14, 2019 to July 1, 2019. The Plan has covered 100 days of SNF care. Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. You will be eligible for a new benefit period when you have not been receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided August 20, 2019 to September 11, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the acupuncture services provided August 22, 2019.You asked the Plan to pay for the acupuncture services. You say that please review this case and have it processed accordingly. Claims are being denied for no acupuncture benefits however this enrollee's contract has acupuncture as a benefit.The Plan denied your request. The Plan says this service is not a covered benefit.The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. The services at issue in this appeal are acupuncture services. The health plan contract specifically says that acupuncture is not covered under any condition. You can find this information on page 44 of the plan's 2019 Evidence of Coverage.Therefore, we decided that the Plan does not have to pay for the acupuncture services provided August 22, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the sacroiliac joint injection provided by on June 6, 2019.
You asked the Plan to reduce the copayment for the sacroiliac joint injection. You say that you were never told you were in a separate facility from the doctor's office and that there would be an additional charge. You say in 2018 you were billed a $38.02 copayment for the same procedure. 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 $295 copayment for Medicare-covered surgery or other services provided to you at an ambulatory surgical center, including but not limited to hospital or other facility charges and physician or surgical charges. You have been asked to pay a $295 copayment for the sacroiliac joint injection. The sacroiliac joint injection falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. The record shows the injection is considered a surgical procedure that was performed at an ambulatory surgical center.
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 sacroiliac joint injection provided on June 6, 2019.
Our decision is only about the 2019 service. If you have any questions about prior years billing, please contact the plan directly.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF admission and services for the enrollee.
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says the enrollee does
not require skilled therapy services or care for complex medical needs.
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 SNF services. Our physician reviewer
found that from a nursing perspective, the enrollee had stable vital signs, and her lungs were clear. There are no
identifiable skilled nursing service needs. Regarding rehab services, the enrollee is at standby assist to minimal
assist for transfers. She could ambulate with moderate handheld assist. She requires varying assist with
activities of daily living. Although there are identifiable skilled therapy service needs, the enrollee does not
require skilled nursing or therapy services on a daily basis.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not
have to pre-approve skilled nursing facility (SNF) admission and services for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveTrue Metrix Glucose Test Strips at a lower cost (tier exception).You asked the Plan to pre-approveTrue Metrix Glucose Test Strips at a lower cost (tier exception). You say that you would like the Plan to reconsider your request.The Plan denied your request. The Plan says tier exceptions only apply to Part D drugs.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 0% coinsurance for Diabetes self-monitoring supplies. We looked at the file, the Plan's contract and Medicare rules. In this case, you are requesting a tier exception for True Metrix Glucose Test Strips. Medicare says that tier exceptions only apply to Part D drugs. Under Medicare rules, your request is not covered for a tier exception because testing strips are not Part D drugs. The Plan's contract clearly states that blood glucose test strips fall under the Diabetes self-monitoring supplies benefit category. The enrollee would have a 0% coinsurance for the blood glucose test strips under the Diabetes self-monitoring supplies benefit category.Therefore, we decided that the Plan does not have to pre-approveTrue Metrix Glucose Test Strips at a lower cost (tier exception).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the sleep study provided on October 24, 2019.You asked the Plan to waive the copayment for the sleep study. You say that the sleep study was done at the same location. You say that you do not agree with the costs.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 $200 copayment for a sleep study at an in-network specialist's office. You have been asked to pay a $200 copayment for the sleep study. The sleep study 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 for the sleep study provided on October 24, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee on April 5, 2018.
You asked the Plan to pay for the services. You say that the claim was filed timely. The Plan denied your request. The Plan says the claim was filed after the timely filing limit.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service. The record shows that a claim for the services was not filed until October 30, 2019. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the services provided to the enrollee on April 5, 2018.
Appeal type: Lab
Decision: Partially Favorable

We decided that the Plan has to pre-approvethe BRCA 1 and 2 testing. We decided that the Plan does not have to pre-approvethe remaining tests. You asked the Plan to pre-approvethe testing. You say that this is medically necessary.The Plan says that all genes in the panel are not relevant to your personal and family history.We decided that the Planhas to pre-approvethe BRCA 1 and 2 testing.The Plan follows Medicare rules. Medicare rules say that genetic testing is 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 for the denied testing. Our reviewer says that only the BRCA 1 and 2 testing is medically reasonable and necessary. Our physician reviewer found that the enrollee is over age 60, with metastatic triple negative breast cancer, with progression of carboplatin/taxol.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 BRCA 1 and 2 testing have been met.Therefore, we decided that the Plan hasto pre-approvethe BRCA 1 and 2 testing. We also decided that the Plan does not have to pre-approvethe remaining tests.The Plan follows Medicare rules. Medicare rules say that genetic testing is 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 for the remaining tests. Our reviewer says that the remaining testing at issue in this case were not medically reasonable or 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 remaining tests have not been met.Therefore, we decided that the Plan does not have to pre-approvethe remaining tests.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ALS emergency ambulance services (A0427 and ground mileage (A0425) provided September 27, 2018.You asked the Plan to pay forthe ambulance service. You say that you originally was provided incorrect insurance information and did not receive correct information until filing limits had passed.The Plan denied your request. The Plan says the claim was filed after the timely filing limitations.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service.The record shows that a claim for the ambulance service was not filed until December 2, 2019. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay forthe ALS emergency ambulance services (A0427 and ground mileage (A0425) provided September 27, 2018.