Persius/hicric huggingface dataset:
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 your 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 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 based on the medical records provided the complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. It is not clear you 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: Imaging
Decision: Partially Favorable

We decided that the Plan has to waive the coinsurance for the drug administration. We decided that the Plan does not have to waive the copayment for the SPECT test. 

You asked the Plan to waive the cost share for the SPECT test and the drug administration. You say that the charges should be reversed. You say you should only be charged if you have the tests done a second time. The Plan says that you have been charged the correct cost sharing amount.

We decided that the Plan has to waive the coinsurance for the drug administration. 

The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles, and coinsurance). The records show that you were charged a $27.41 coinsurance for code 96374. The record shows this code is for the administration of a drug which is considered a physician service.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not include a complete Evidence of Coverage showing how much an enrollee would expect to pay for a physician's service. Therefore, we decided that the Plan has to waive the coinsurance for the drug administration provided on August 19, 2020.
 
We also decided that the Plan does not have to waive the copayment for the SPECT test.
	
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 $225 copayment for the SPECT test. Therefore, we decided that the Plan does not have to waive the copayment for the SPECT test.

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.
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 LTACHservices. You say that these services are medically necessary.The Plan denied your request. The Plan says that the enrollee can safely receive needed care in another setting, such as a skilled nursing facility or home with home health 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 patient is currently undergoing treatment at an acute care hospital (ACH) for CoViD-19. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. 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 needs. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services.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 pay for physician services (99226) provided August 31, 2019.
You asked the Plan to pay for the physician services. You say that there was a delay in receiving information
from the rendering facility and the claim should be paid. The Plan denied your request. The Plan says the claim
was filed untimely.
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 physician services was not filed until September 15, 2020. 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 physician services (99226) provided August 31, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee on April 23, 2019, by an out-of-network provider.You asked the Plan to pay forthe medical services. You say that they did not receive this enrollee's benefit determination, hence, the untimely submission of the claim.The Plan denied your request. The Plan says the stay is not medically necessary.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 original claim has a processed date of June 13, 2019, and this corrected claim was received on September 14, 2020. 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 medical services provided to the enrollee on April 23, 2019, by an out-of-network provider.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay forthe transportation and set up of the portable x-ray (Q0092 and R0070) provided on June 27, 2020.You asked the Plan to pay forthe transportation and set up of the portable x-ray. You say that you would like reconsideration because this service was billed correctly.The Plan denied your request. The Plan says that this service is subject to consolidated billing.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find that CPT code Q0092 and R0070is supported in the record. Specifically, the record does not show that the member was in a Part A covered stay.This claim was billed with place of service code 13, indicating the services were rendered at an assisted living facility. The transportation and set up of the x-ray is separately billable for Medicare Part B members. Based on this information, we decidedthat Medicare rules for coverage of the transportation and set up of the portable x-ray have been met.Therefore, we decided that the Plan has to pay forthe transportation and set up of the portable x-ray (Q0092 and R0070) provided on June 27, 2020.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.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory testing provided on July 31,
2020.
You asked the Plan to waive the copayment for lab test. You say that you were not informed that there was a
copayment for lab testing. 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 $6
copayment for lab test.
You have been asked to pay $6 copayment for lab test. Lab test 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
laboratory testing provided on July 31, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services provided on June 17, 2020.You asked the Plan to pay forthe ambulance services. The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on June 17, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have topay forthe ambulance services provided on June 17, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran x-ray (73030) provided August 27, 2020.You asked the Plan to waive the copayment forthe x-ray. You say that the x-ray should be included in the cost of the office visit and there should not be a separate copayment.The Plan denied your request. The Plan says the correct copayment 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 a $45 copayment for Outpatient Diagnostic Tests. You have been asked to pay the allowable amount of $32.07 as a copayment for the x-ray. The x-ray falls within the Outpatient Diagnostic Tests benefit category. In this case the allowable amount is less than the $45 copayment noted in the plan contract.The x-ray was a separate and distinct service from the office visit.This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment foran x-ray (73030) provided August 27, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay foranti-reflective coatingand tints (V2750 and V2744) provided on June 2, 2020.You asked the Plan to pay forthe anti-reflective coating and tints. You say that you would like reconsideration because this is a covered service per the EOC.The Plan denied your request. The Plan says this is not a covered benefit.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 pay for the anti-reflective coating and tints. Our reviewer says that the documentation does not support that anti-reflective coating and tints were medically reasonable and necessary for you 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 anti-reflective coating and tints have not been met.Therefore, we decided that the Plan does not have to pay foranti-reflective coating and tints (V2750 and V2744) provided on June 2, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.
You asked the Plan to pre-approve Prolia. You say that you would like reconsideration because this drug is
medically necessary. The Plan denied your request. The Plan says the member does not meet step therapy
exception criteria.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.
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 Prolia. Our reviewer says that the
documentation does not support a history if an osteoporotic fracture or previous treatment, contraindication, or
intolerance to zoledronic acid and an oral bisphosphonate drug. Our physician reviewer found step therapy, as
outlined by the plan, requires this documentation. Without the support of the documentation, Prolia is not
approved as step criteria is not met.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to
pre-approve Prolia.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided from May 7, 2020, through October 7, 2020, by an out-of-network provider.You asked the Plan to pay forthe medical services. You say that the claim should be paid.The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider and the services were not urgent or emergent, nor were they approved in advance.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 had network providers available who could have provided 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 forthe medical services provided from May 7, 2020, through October 7, 2020, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve low vision aid services.
You asked the Plan to pre-approve the requested services. You say that you would like to try and save the eye
sight in your right eye. The Plan denied your request. The Plan says the service is not covered by Medicare or
your plan.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for low vision aids.
The file shows that an exam and testing for low vision aids were requested. We looked at the file and the rules.
Medicare does not pay for low vision aids. Services related to non-covered services are not covered under
Medicare. Therefore, we decided that the Plan does not have to pre-approve low vision aid services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe office visit -after regularly scheduled hours (D9440) and re-cement or re-bond crown (D2920) provided on September 21, 2020.You asked the Plan to pay forthe dental services. You say that the dental services should be covered.The Plan denied your request. The Plan says your plan does not cover the re-cement or re-bond of crown for tooth #6 and after hours office visit performed on September 21, 2020.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, the requested itemsor services are not among those covered under this benefit. The services are not listed in your EOC as a covered benefit; therefore, they are not covered.Therefore, we decided that the Plan does not have to pay forthe office visit -after regularly scheduled hours (D9440) and re-cement or re-bond crown (D2920) provided on September 21, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveblepharoplasty.You asked the Planto pre-approvethe surgery. You say that this is medically necessary.The Plandenied your request. The Plansaysthe medical need has not been shown as the MRD is over 2.0mm.The Plan must follow Medicare rules. Medicare rules say that blepharoplasty is covered when it is considered functional.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 surgery. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found upper eyelid blepharoplasty is medically necessary in this case based on the functional complaints, visual field results and physical exam. In this case, it is clear that you have dermatochalasis as evidenced by photographs with eyelids touching the lash margin. The physical examination demonstrates MRD that does not meet criteria for coverage, however visual field tests are consistent with a functional deficit. Medicare LCD criteria allow for exception to the MRD criteria when there is compelling evidence of functional disability based on history and visual field information. The visual fields, history and photographs are compelling evidence of functional disability in spite of the MRD measurements that do not meet 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 surgery have been met.Therefore, we decided that the Plandoes not haveto pre-approveblepharoplasty
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the CT scan (CPT Code 72193) to be performed by an out-of-network provider.
You asked the Plan to pre-approve the CT scan. You say that you are requesting review of denial of services to be provided by an out-of-network provider. The Plan denied your request. The Plan says there are network providers that can perform the service.
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-approve the CT scan (CPT Code 72193) to be performed by an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approveVertiflex SuperionDevice placement for the enrollee.You asked the Plan to pre-approvethese services. You say that these services are medically necessary.The Plan denied your request. The Plan says that experimental and investigational procedures are not coveredby Medicare.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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Current evidence based medical guideline and peer reviewed literature do not fully support the spinal decompression device procedure over the 'gold standard' of lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollee's medical condition. FDA indications include implantation of the Superion device at one or two adjacent lumbar levels in patients with moderate spinal stenosis in whom operative treatment is indicated at no more than two levels, from L1 to L5.  There was no diagnostic testing provided to demonstrate the evidence of spinal stenosis. FDA contraindications include spinal scoliosis, obesity, and osteoporosis, and have not been adequately addressed in the medical records. Superion indirect lumbar decompression would not be considered the standard of care for the enrollee's medical condition. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for coverage of these services.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-approveVertiflex Superion Device placement for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a psychiatric diagnostic evaluation provided on August 6, 2019.You asked the Plan to pay for the psychiatric diagnostic evaluation. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requiresauthorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented. Medicare rules say that plans can require enrollees to get care from network providers. The contractwith 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 thePlan. 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 a psychiatric diagnostic evaluation provided on August 6, 2019.