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

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on June 25, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.

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 services at issue in this appeal. The Plan did not pre-approve the services at 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 the services provided by an out-of-network provider on June 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve addition, endoskeletal knee/shin system, 4-bar linkage or multiaxial, pneumatic swing phase control (CPT code L5840), all lower extremity prostheses, flex-walk system or equal (CPT code L5981), and addition, endoskeletal system, above knee or hip disarticulation, knee extension assist (CPT code L5850).

You asked the Plan to pre-approve the items. You say that the items requested are urgently needed for you to be able to ambulate. The Plan denied your request. The Plan says the items are not 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 items. Our physician reviewer found the reviewed records do not support functional status has advanced to K3, as your physician does not corroborate prosthetist's (vendor's) claim that you are K3 ambulator. The review has determined that the requested items are not medically necessary and 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 items have not been met. Therefore, we decided that the Plan does not have to pre-approve addition, endoskeletal knee/shin system, 4-bar linkage or multiaxial, pneumatic swing phase control (CPT code L5840), all lower extremity prostheses, flex-walk system or equal (CPT code L5981), and addition, endoskeletal system, above knee or hip disarticulation, knee extension assist (CPT code L5850).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network services provided to the enrollee on February 15, 2021.

You asked the Plan to pay for out of network services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network 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 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 for out of network services provided to the enrollee on February 15, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ten (10) additional ST visits.

You asked the Plan to pre-approve ten (10) additional ST visits. You say that additional ST is medically necessary. The Plan denied your request. The Plan says additional ST is not medically necessary and not covered by Medicare.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve ten (10) additional ST visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that you have previously been treated with outpatient therapies and should be independent with a home exercise program. There is no documentation of a recent injury or decline in function. The additional therapy services are not an appropriate duration and frequency for treatment of your medical condition and therefore are not medically 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 ten (10) additional ST visits have not been met. Therefore, we decided that the Plan does not have to pre-approve ten (10) additional ST visits.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Spinal Fusion, Lumbar (CPT code(s): 22840, 20936, 22633, 22853), for the enrollee.

You asked the Plan to pre-approve the services. You say that the surgery is necessary because the enrollee has an L5-S1 far lateral disc herniation with left lower extremity radiculopathy. You state the only way to access the compression of the L5 nerve root is via facetectomy which would all decompression of the disc. You state the enrollee's conservative treatments have not been helpful and was offered injections but does not want to do those. The Plan denied your request. 

The Plan says there is no radiographic or clinical evidence of instability nor does the medical record reflect disc compression or neural elements at the level being requested for fusion.

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 criteria for lumbar surgery not met. Injection therapy must be tried and failed. More conservative measures are needed. 

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 Spinal Fusion, Lumbar (CPT code(s): 22840, 20936, 22633, 22853), 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 an IRF is medically necessary. The Plan denied your request. The Plan says an IRF is not medically necessary. The enrollee can safely receive the necessary care in a less intensive setting.
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 that the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The
enrollee does require physical and occupational therapy, but there is no documented need for an intensive rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Medically necessary services can be provided in a different 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy provided from September 3, 2020, through September 24, 2020.
You asked the Plan to waive the copayment for physical therapy. You say that you were not aware of a copayment and you are getting bills from the provider. The Plan denied your request. The Plan says the copayments 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 $35 copayment per Medicare-covered visit of physical therapy, occupational therapy, and speech language therapy services.
You have been asked to pay a $35 copayment for each physical therapy visit. The total amount you owe is $210 ($35/visit x 6 visits = $210). Physical therapy falls within the "Outpatient rehabilitation 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 physical therapy provided from September 3, 2020, through September 24, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on September 15, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.
We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on September 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the periodic oral evaluation, bitewing x-rays, first intraoral periapical x-ray, each additional intraoral periapical x-ray, and prophylaxis provided on March 11, 2021 by an OON provider.
You asked the Plan to pay more for the periodic oral evaluation, bitewing x-rays, intraoral periapical x-rays, and prophylaxis. You say that you should not be billed for preventive dental services. The Plan denied your request. The Plan says the treating provider does not have a contract with the Plan as a participating provider and is allowed to bill the difference of the allowed amount and their billed amount to you.
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, you are responsible for the difference between the billed amount and allowed amount for services received OON. Therefore, we decided that the Plan does not have to pay more for the periodic oral evaluation, bitewing x-rays, first intraoral periapical x-ray, each additional intraoral periapical x-ray, and prophylaxis provided on March 11, 2021 by an OON provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid (U0003 and U0005) provided on January 11, 2021.
You asked the Plan to pay for the infectious agent detection. You say that you would like this claim to be reprocessed for payment. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services.
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore,
we decided that the Plan does not have to pay for the infectious agent detection by nucleic acid (U0003 and
U0005) provided on January 11, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay from January 24 through February 23, 2021.

You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you were not aware that inpatient hospital stays would be this expensive and you cannot afford this copayment. The Plan denied your request. The Plan says the correct cost share applied to the claim.

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 $350 copayment per day for days 1 - 5 for Inpatient Hospital Care. 

You have been asked to pay a $1750 copayment ($350 per day for days 1 - 5, and $0 per day after day 5) for the inpatient hospital stay. The inpatient hospital stay falls within the Inpatient Hospital 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 the inpatient hospital stay from January 24 through February 23, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care provided on March 22, 2021.
You asked the Plan to waive the copayment for emergency care. You say that you did not want to go to the emergency room and was forced to go. The Plan denied your request. The Plan says the claims were processed correctly, and you are being charged the correct 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 $90 copayment for emergency care.
You have been asked to pay a $90 copayment for emergency care. Emergency care 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 emergency care provided on March 22, 2021.
We note your complaint that you did not want to go to the emergency room and were forced to go. Your complaint is a grievance that must be answered by the health plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the facet joint radiofrequency ablation services.

You asked the Plan to pre-approve the facet joint radiofrequency ablation services. You say that this procedure is medically necessary for your pain. The Plan denied your request. The Plan says the criteria for coverage have not been met.

The Plan must follow Medicare rules. Medicare rules say that in order for therapeutic facet joint procedures to be considered medically reasonable and necessary, the diagnostic facet joint procedures must have provided at minimum 80% relief of primary (index) pain. 

We looked at the file and Medicare rules. In this case, the medical records indicate that you have not had a 80% relief of primary pain from both diagnostic facet joint procedures. Based on this information, we decided that Medicare rules for coverage of the facet joint radiofrequency ablation services have not been met. Therefore, we decided that the Plan does not have to pre-approve the facet joint radiofrequency ablation services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on January 12, 2021, by an OON provider.
You asked the Plan to pay for an office visit. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained for these 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 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 for an office visit provided on January 12, 2021, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the home ventilator with a non invasive-interface.

You asked the Plan to pre-approve the home ventilator with a non invasive-interface. You say that you would like reconsideration because the home ventilator is medically necessary. The Plan denied your request. The Plan says there are no recent clinical details provided that confirm failure with the use of a BIPAP E0471 device.

The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD.

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 home ventilator with a non invasive-interface. Our reviewer says that the member does not meet criteria for the home ventilator. Our physician reviewer found Medicare does not cover a home ventilator when used as BiPAP. Certain BiPAP devices can provide the AVAPS mode of support that is ordered. The patient improved on BiPAP in the hospital, and there is no evidence of BiPAP failure. 

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 home ventilator with a non invasive-interface have not been met. Therefore, we decided that the Plan does not have to pre-approve the home ventilator with a non invasive-interface.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the MRI provided on October 8, 2020.

You asked the Plan to waive the copayment for the MRI. You say that there was no mention you would be responsible for a $125 charge at the time of service. You say that you are appealing this charge on the basis that the cost was not mentioned and the lengthy delay in billing. 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 $125 copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a physician's office or at a free-standing facility (such as a radiology center or medical clinic). 

You have been asked to pay a $125 copayment for the MRI. The MRI 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 MRI provided on October 8, 2020.
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 this is medically necessary. The Plan denied your request. The Plan says there is no special treatment needed.

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 the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for pneumonia, congestive heart failure, and osteomyelitis. Medical problems are stable.

There are no complex nursing or rehabilitation needs. The enrollee does 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 this enrollee 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 acute inpatient rehabilitation facility (IRF) admission and services.