Persius/hicric huggingface dataset:
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 LTACH admission is medically necessary. The Plan denied your request. The Plan says the member is receiving appropriate care at the current acute setting and does not require transfer to an LTACH.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 there were no observed medical services required of the member that were only available at the proposed LTACH that are not already being offered at the current acute care setting. Continued care at the current facility would be safe and effective until discharge to a lower level of care is secured.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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from September 5, 2019 through September 11, 2019.You asked the Plan to waive the copayment for inpatient hospital care. You say that the two different stays should be considered as one stay, instead of two (2) different stays.The Plan denied your request. The Plan says the claim was 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 show that you received inpatient hospital care from September 5, 2019 through September 11, 2019. You are asked to pay a $200 copayment per day, days 1-7 (per Medicare-covered stay) which includes day of admission and day of discharge. Your EOC states you pay the copayments each time you are admitted. 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 inpatient hospital care from September 5, 2019through September 11, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the laboratory work provided on September 12, 2019.
You asked the Plan to waive the cost share for the laboratory work. You say that the genetic testing should be covered because it is medically necessary. 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. Your contract with the Plan says that there is a $500 deductible that applies towards out-of-network laboratory work and 30% coinsurance after the deductible is met for diagnostic lab services and diagnostic procedures and tests (per day, per facility). The laboratory work you asked the Plan to waive the cost share for falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible that applies towards out-of-network laboratory work and 30% coinsurance after the deductible is met for diagnostic lab services and diagnostic procedures and tests (per day, per facility). The record shows the provider is out-of-network. See chart below.
Date of Service
Service
Allowed Amount
Coinsurance/Deductible
Member Liability
September 12, 2019
BRCA1 & BRCA2 analysis
$2,027.64
$500
$391.95 - This is where you met your $500 deductible amount
September 12, 2019
BRCA1 & BRCA2 analysis
$1,635.69 - This is the remaining allowed amount ($2,027.64 - $391.95)
30%
$490.70
September 12, 2019
APC gene analysis
$780.00
30%
$234.00
September 12, 2019
MLHI gene analysis
$675.40
30%
$202.62
September 12, 2019
MLH1 gene analysis duplication
$202.40
30%
$60.72
September 12, 2019
MSH2 gene analysis
$381.70
30%
$114.51
September 12, 2019
MSH2 gene analysis duplication
$213.30
30%
$63.99
September 12, 2019
MSH6 gene analysis
$641.85
30%
$192.55
September 12, 2019
MSH6 gene analysis duplication
$238.00
30%
$71.40
September 12, 2019
PMS2 gene analysis
$676.50
30%
$202.95
September 12, 2019
PMS2 gene analysis duplication
$203.50
30%
$61.05
Total
$2,086.44
This cost sharing is a contractual obligation that had not been met at the time the laboratory work was received on September 12, 2019. Therefore, we decided that the Plan does not have to waive the cost share for the laboratory work provided on September 12, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on October 28, 2019.
You asked the Plan to waive the copayment for the ambulance transport. You say that this copayment is too high. The Plan denied your request. The Plan says that they copayment was appropriately assessed.
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 $300 copayment per one-way trip for emergency ambulance services and non-emergency ambulance services. You have been asked to pay a $300 copayment for the ambulance transport. The ambulance transport falls within the one-way trip for emergency ambulance services and non-emergency ambulance services 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 ambulance transport provided on October 28, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe wrist hand orthosis provided on August 14, 2018 by an out of network provider.You asked the Plan to pay forthe wrist hand orthosis (L3908). You say that the orthosis was medically necessary.The Plan denied your request. The Plan says you did not get prior authorization.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 providerwith the Plan. The Plan has network providers available who can provide the itemat issue in this appeal. The Plan did not pre-approve the itemat issue. We found no exception that would require the Plan to pay for this item.Therefore, we decided that the Plan does not have to pay forthe wrist hand orthosis provided on August 14, 2018 by an out of network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to adjust the copayment for the ambulance service and the emergency room service provided on July 11, 2019.
You asked the Plan to adjust the copayment for the ambulance service and ER service. You say that you should only have a $50 ambulance copayment. The Plan denied your request. The Plan says you were charged this cost sharing 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 $50 copayment for each ambulance trip. You had one ambulance trip. The Plan charged you $50 for these services. 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.
Your contract with the Plan clearly says that you must pay a $50 copayment for each emergency visit. The Plan charged you $26.53, less than your copayment, for the service. The copayment was less because you had reached your maximum out-of-pocket for 2019 when the claim was submitted. Therefore, we decided that the Plan does not have to adjust the copayment for the ambulance service and the emergency room service provided on July 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveEuflexxa injections.You asked the Plan to pre-approvethe Euflexxa injections. You say that this injection should be covered every six months since it is helpful to the enrollee.The Plan denied your request. The Plan says there is no documentation of the level of benefit provided by prior injections. As such, repeat treatment is not considered reasonable and necessary.The Plan follows Medicare rules. Medicare rules say that viscosupplementation injections are covered when reasonable and necessary based on the above referenced criteria. Repeat injections are covered when there is evidence of benefit for at least six months from prior treatments. 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 Euflexxa injections. Our reviewer says that the documentation does not support that criteria for this treatment are met. Our physician reviewer found this enrollee has a history of symptomatic right knee osteoarthritis. She was last treated with Euflexxa injections for the right knee in July 2019, and benefit was noted with previous Orthovisc injections. Under consideration is a request for Euflexxa injections for the right knee. Medicare coverage criteria have not been fully met. There is radiographic evidence of osteoarthritis of the knee with joint space narrowing, subchondral sclerosis, and osteophytes. However, there is no detailed documentation of current right knee pain and/or functional assessment. There is no documentation of a significant improvement in pain and functional capacity achieved with the July 2019 injections using a standardized assessment tool, or evidence of a significant reduction in doses of NSAID medications taken or reduction in the number of intra-articular steroid injections to the knees during the 6-month period followingthe injection to support repeat injections. Therefore, this enrollee does not meet the LCD criteria for the requested Euflexxa injection.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 Euflexxa injections have not been met.Therefore, we decided that the Plan does not have to pre-approveEuflexxa injections.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on October 2, 2019.
You asked the Plan to waive the copayment for the ambulance transport. You say that you cannot afford this. The Plan denied your request. The Plan says that the 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). Your contract with the Plan clearly says that you must pay a $265 copayment per date of service regardless of the number of ground ambulance trips. You have been asked to pay a $265 copayment for the ambulance transport. The ambulance transport falls within ground ambulance trips 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 ambulance transport provided on October 2, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on March 15, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on March 15, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) care.You asked the Plan to pre-approveSNF 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 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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based onavailable records, the enrollee does not meet criteria for coverage of SNF. The records do not support that the enrollee needs or can actively participate in daily physical therapy (PT) and occupational therapy (OT). There are no noted daily skilled complex nursing needs. While they may benefit from continuing PT and OT, the records do not support the need for daily therapy.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-approveskilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99203), and a medical eye exam (1036F, G9903) provided on May 22, 2019 by an out of network (OON) provider.
You asked the Plan to pay for an office visit, and a medical eye exam. You say that you went to your primary physician with irritated eyes, they were bloodshot and hurting for treatment. He suspected glaucoma and referred you to a physician. The physician said there was no sign of glaucoma and advised you on treatments to help. The Plan denied your request. The Plan says the services were not urgent nor were they emergent. There was sufficient time to request prior authorization for out-of-network provider services. It is the responsibility of the member and the provider to check benefits and coverage prior to receiving and providing services.
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 an office visit (99203), and a medical eye exam (1036F, G9903) provided on May 22, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forinpatient care provided from September 26, 2019 to September 27, 2019.You asked the Plan to pay forinpatient care. You say that inpatient admission was medically necessary.The Plan denied your request. The Plan says the enrollee's status improved andwassenthome with medications. Based on the clinical records provided this participant's care did not meet medical necessity criteria for acute inpatient hospital level of care. Participants care needs could have been provided in an alternative care level such as observation status or acute nursing facility. A short period of observation care and the participant could have returned home or to a sub-acute nursing facility or long-term nursing care (the participant's PACE interdisciplinary team) for out-patient observation and continued medical management.The Plan must followMedicare rules. Medicare rules say that PACE plans must cover all services determined necessary by the IDT to improve and maintain the enrollee's overall health status.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 inpatient care. Our reviewer says that the service was not medically necessary. Our physician reviewer found that the enrollee presented to the emergency department (ED) on September 26, 2019 for evaluation of 3 episodes of chest pain and shortness of breath. The ED documentation showed no acute distress. No documented chest pain, vomiting, back pain, or stroke like symptoms. The enrollee had no remarkable chest x-ray findings for acute cardiopulmonary disease. There was no evidence of congestive heart failure (CHF) exacerbation. The enrollee's exam showed the enrollee medically stable with no acute distress. She admitted to the hospital with a diagnosis of CHF and her condition stabilized and improved. She was discharged home on September 27, 2019 with outpatient follow-up. The review indicates that the member was stable and appropriate for observation level of care services after the emergency room evaluation on September 26, 2019.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient care werenot met.Therefore, we decided that the Plan does not have to pay forinpatient care provided from September 26, 2019 to September 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea referral to an out-of-network provider.You asked the Plan to pre-approvethese services. You say that you went to the in-network providers without success.The Plan denied your request. The Plan says the services are available from network 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 items/services at issue in this appeal. The Plan has network providers that you havenot seen that can provide the same level of care as the requested provider. 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 referral to an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for comprehensive eye exam (92004) and refraction (92015) provided April 4, 2019.
You asked the Plan to waive the copayment for the vision services. You say that when you scheduled this appointment you was told that the doctor was in-network and you would be covered. You believe you should not have to pay the $71.84 for the eye exam. The Plan denied your request. The Plan says the claim was processed correctly and the correct cost share was applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 45% for services performed by an out of network provider for Vision care. You have been asked to pay $71.87. You must pay 45% for services performed by an out of network provider. for the vision services. The vision services fall within the Vision 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 comprehensive eye exam (92004) and refraction (92015) provided April 4, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis provided on June 3, 2019.

You asked the Plan to pay for the knee orthosis (L1851). You say that the orthosis was medically necessary. The Plan denied your request. The Plan says rules for telehealth services were not met.

The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.
 
A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for the knee orthosis provided on June 3, 2019.