Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for AED (CPT code K0606RR) provided on September 25, 2020, by an out-of-network provider.

You asked the Plan to waive the coinsurance for the DME. You say that the provider convinced you to try the equipment and you did, but eventually returned the equipment to the provider. The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC benefits.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance).

Review of the file show that you received an AED (CPT code K0606RR) on September 25, 2020, by an out-of-network provider. You were asked to pay 30% coinsurance for the AED. Your 2020 EOC states that enrollees
must pay 30% coinsurance per out-of-network DME. The plan will reimburse a maximum of $1,500 for out-of-network (POS) services per calendar year. 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 AED (CPT code K0606RR) provided on September 25, 2020, by an out-of-network provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit provided on February 28, 2021.
You asked the Plan to waive the copayment for emergency room visit. You say that you do not feel you should owe this to the provider. The Plan denied your request. The Plan says the copayment amount 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 $90 copayment for emergency room visit. You have been asked to pay $90 copayment for emergency room visit. Emergency room 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 an emergency room visit provided on February 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the in network rate for the complete series x-ray (D0210), the unspecified preventive service (D1999), and the complete series x-ray, interpretation only (D0709) provided on January 7, 2021.

You asked the Plan to pay the in network rate for the dental services. You say that you were told that this provider accepted your insurance. You say that you received a letter advising that the provider was out of network. You say that The Plan denied your request. The Plan says this provider was out of network on the date of service in this case. The Plan says that dental services performed out of network are not covered. The Plan also says that the complete series x-rays, and the unspecified preventive service are not listed as covered services.

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, dental services performed out of network are not among those covered under this benefit. Additionally, regardless of the provider status, the services are not listed as covered services. Therefore, we decided that the Plan does not have to pay the in network rate for the complete series x-ray (D0210), the unspecified preventive service (D1999), and the complete series x-ray, interpretation only (D0709) provided on January 7, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for anesthesia services provided on November 16, 2020, by an OON
provider.
You asked the Plan to pay for anesthesia services. You say that you would like this claim reprocessed and
approved for payment. The Plan denied your request. The Plan says that prior authorization was not obtained
for these services rendered by an OON provider.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that you can receive your care from either a network provider or an out-of-network provider.
The requested provider in this case is not a network provider with the Plan. However, the Plan's contract
indicates that they will cover services provided by an OON provider. Therefore, we decided that the Plan has to
pay for anesthesia services provided on November 16, 2020, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Shingrix vaccine provided on January 20, 2021.
You asked the Plan to pay for the Shingrix vaccine. You say that you would like the Plan to reconsider their
denial of payment. The Plan denied your request. The Plan says the Shingrix vaccine is not covered under your
Medicare Part B benefit.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Shingrix
vaccine. The Plan follows the same rules.
Records do not show that you have been injured or directly exposed to any illness related to the Shingrix
vaccine. Therefore, we decided that the Plan does not have to pay for the Shingrix vaccine provided on January
20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued rental of a CPAP device (E0601).
You asked the Plan to pre-approve a CPAP. You say that the requested item is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for a CPAP have not been met.
The Plan must follow Medicare rules. Medicare rules say that continued coverage of a PAP device requires objective evidence of adherence to use of the PAP device, defined as use of PAP &#8805;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. Based on this information, we decided that Medicare rules for coverage of a CPAP have not been met. Specifically, provided compliance reports show that the enrollee does not use the CPAP &#8805;4 hours per night on 70% of nights. Therefore, we decided that the Plan does not have to pre-approve continued rental of a CPAP device (E0601).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
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 needed care can be safely given in a lower level of care, such as skilled or subacute nursing care 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. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for surgical treatment of bilateral femur fractures, left talar fracture, right tib-fib fracture after a motor vehicle collision. Medical problems 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. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care 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. 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).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the foot orthotics provided September 28, 2020.
You asked the Plan to waive the coinsurance for the foot orthotics. You say that you would like this cost share waived. The Plan denied your request. The Plan says the claim 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). The enrollee's contract with the Plan clearly says that enrollees must pay a 20% coinsurance for Medicare-covered therapeutic shoes. The enrollee has been asked to pay a total cost share of $54.27 ($271.36 Medicare allowed amount x 20% coinsurance). The foot orthotics fall within the Medicare-covered therapeutic shoes 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 the Plan does not have to waive the coinsurance for the foot orthotics provided September 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the FreeStyle Libre 14 day reader and sensors (K0553 and K0554) provided on December 31, 2020.
You asked the Plan to pay for the FreeStyle Libre reader and sensors. The Plan denied your request. The Plan says the documentation submitted did not sufficiently document the enrollee's medical condition to support the medical necessity for the billed supply code. The Plan also says that the documentation does not indicate the provider discussed the need for the billed supply code. The Plan follows Medicare rules. Medicare rules say that therapeutic CGMs may be considered reasonable and necessary for enrollees with diabetes who meet the criteria referenced 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 pay for the FreeStyle Libre reader and sensors. Our reviewer says that the FreeStyle Libre 14 day reader and sensors (K0553 and K0554) are not medically reasonable and necessary for the enrollee. Our physician reviewer found in order for a continuous glucose monitor (CGM) to be covered, the enrollee must be checking their blood glucose (BG) 4 times per day, and adjusting insulin doses according to their BG level. We are not told that this is occurring with this enrollee at this time. Our reviewer also found that although the CGM would likely benefit the enrollee, there is insufficient data here to prove medical necessity by the provided criteria. 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 FreeStyle Libre reader and sensors have not been met. Therefore, we decided that the Plan does not have to pay for the FreeStyle Libre 14 day reader and sensors (K0553 and K0554) provided on December 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ophthalmology services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve OON services. You say that your vision is obscured. The Plan denied your request. The Plan says the requested service may be provided by participating providers.
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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve ophthalmology services to be provided by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve PET with concurrently acquired CT for attenuation
correction and anatomical localization imaging; whole body (CPT code 78816), for the enrollee.
You asked the Plan to pre-approve the PET scan. You say that you are requesting a PET scan with CT for
attenuation due to the enrollee having belly problems. The Plan denied your request. The Plan says this request
exceeds the number of PET scans nationally covered per the NCDs.
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are
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 PET scan. Our physician reviewer
found the enrollee had a PET scan in 2020 showing improvement of carcinomatosis in the peritoneum but
showed new nodules. CT scan from March 15, 2021, showed increased size and number of retroperitoneal
nodes and peri-aortal nodes. A fourth PET scan with CT was requested. The provided documentation does not
support this request as results of another PET scan are not likely to change the treatment options and overall
outcome considering the extent and condition of this patient. Therefore, this request for PET with CT will be
considered not medically necessary. Another study such as MRI or CT alone might be 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 PET scan have not been met. Therefore, we decided that the Plan does not have to preapprove
PET with concurrently acquired CT for attenuation correction and anatomical localization imaging;
whole body (CPT code 78816), 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 IRF admission is medically necessary.The Plan denied your request. The Plan says the enrollee's needs can be met at a different level of 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 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 based on the medical records provided the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. It is not clear the enrollee would be able to fully benefit and/or participate in an IRF 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 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: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for after-hours services (99053) provided September 25, 2020.
You asked the Plan to pay for the after-hours services. You say that these services were medically necessary. The Plan denied your request. The Plan says this service is not eligible for separate payment.
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 code 99053 is Service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service. We find that CPT code 99053 is not supported in the medical record. Specifically, payment for this service is included in payment for the Emergency Room service. Based on this information, we decided that Medicare rules for coverage of the after-hours services have not been met. Therefore, we decided that the Plan does not have to pay for after-hours services (99053) provided September 25, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex superion device placement surgery (CPT Code(s): 22869, 22780, and 99152), for the enrollee.
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says the services are considered experimental and 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 services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy of the device. 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 pre-approve Vertiflex superion device placement surgery (CPT Code(s): 22869, 22780, and 99152), for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied
your request. The Plan says the stay 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 in the Medicare rules section 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 care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found you do not qualify for SNF coverage. You do
not have documented skilled nursing needs. You do not have documented skilled therapy needs. You are
consistently ambulating more than one hundred (100) feet and tending to activities of daily living (ADLs) with
minimal supervision. Daily skilled services are not required to establish a maintenance program or to prevent
deterioration of your condition. Your 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 SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve SNF care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says you are not able to tolerate intensive daily therapy for 3 hours a day.
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 physician reviewer found that you were admitted to the acute hospital for surgical repair of a hip fracture after a fall. Your medical conditions are stable. There are no complex nursing needs. 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. You do require physical and occupational therapy, but there is no documented need for an intensive rehabilitation program.
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 pay for the acute inpatient hospital care provided on October 29 to
October 31, 2020.
You asked the Plan to pay for acute inpatient hospital care. You say that acute inpatient hospital care was a
medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not
been met as a lower level of care would have been more appropriate.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found that the enrollee was transferred to the hospital for possible transcatheter aortic valve replacement (TAVR) procedure due to the enrollee feeling out of breath with exertion for one month. Upon evaluation the enrollee denied shortness of breath, vitals were normal, no hypoxia, labs normal. The documentation from the emergency department did not support that the enrollee required hospital services that were expected to cross 2 midnights due to no acute condition found. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided on October 29 to October 31, 2020.