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

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) service provided October 1, 2019 to October 31, 2019.You asked the Plan to pay for the SNF services. You say that you feel that the plan should cover for SNF services.The Plan denied your request. The Plan says medical necessity cannot be established for continued SNF level of coverage.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 pay for the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing and skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis and does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.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 SNF services have not been met.Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) service provided October 1, 2019 to October 31, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for DecisionDx-Melanoma testing provided on November 18, 2019.
You asked the Plan to pay for DecisionDx-Melanoma test. You say that this test is covered by Medicare. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this test does not meet the Medicare criteria for coverage.
The Plan follows Medicare rules. Medicare rules say that DecisionDx-Melanoma testing is only covered by Medicare when certain specific clinical conditions are met. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for DecisionDx-Melanoma test. Our reviewer says that this test does not meet the Medicare criteria for coverage. Our physician reviewer found the documentation does not support a positive deep margin or other adverse melanoma features in the enrollee.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of DecisionDx-Melanoma test have not been met. Therefore, we decided that the Plan does not have to pay for DecisionDx-Melanoma testing provided on November 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for office visits (99204 and 99214) provided by a naturopath from November 14, 2019 to December 16, 2019.
You asked the Plan to pay for naturopathic office visits. You say that this was the only provider who has been able to address your symptoms. The Plan denied your request. The Plan says naturopathic services are not covered under Medicare.
The Plan must follow Medicare rules. The rules say that Medicare does not cover naturopathic services. The services at issue in this appeal are naturopathic services. Therefore, we decided that the Plan does not have to pay for office visits (99204 and 99214) provided by a naturopath from November 14, 2019 to December 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an epidural injection provided on November 21, 2019.
You asked the Plan to waive the copayment for an epidural injection. You say that you should only owe a specialist copayment. 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 $275 copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers. You received an epidural injection at an outpatient hospital facility on November 21, 2019. An epidural injection is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $275 copayment. You have been asked to pay a $275 copayment for an epidural injection. An epidural injection falls within the outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers 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 epidural injection provided on November 21, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forcomprehensive eye exam (92004) frames (V2025) andlens (V2200) provided on October 21, 2019.You asked the Plan to pay forthe vision services. You say that you pay over $100 a month and feel that this should be covered.The Plan denied your request. The Plan says the $90 out of network benefit was correctly applied to the provider's 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 if you use a non-participating provider, the benefit is limited to $90 per calendar year. You are requesting reimbursement of $316.80 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 pay forcomprehensive eye exam (92004) frames (V2025) and lens (V2200) provided on October 21, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on October 28, 2019.
You asked the Plan to pay for the lab 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 lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on October 28, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve outpatient physical therapy.
You asked the Plan to pre-approve physical therapy. You say that you need physical therapy to increase strength and bring back mobility. The Plan denied your request. The Plan says the denial of authorization for these services is correct, because these physical therapy visits are not medically necessary.
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 physical therapy. 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 the requested therapy is not generally accepted as a specific and effective therapy for your condition. The documentation does not reveal significant objective functional improvement from prior therapy; therefore, an additional 8 visits of therapy cannot be considered effective for this condition. You have had sufficient prior therapy visits and should be able to transition to an independent home exercise program. The unique skills of a professional therapist are not required to safely and effectively provide treatment, be safely and effectively performed only by a therapist, or under the supervision of a therapist. The requested services are not part of a maintenance program. The specialized skill, knowledge, and judgment of a qualified therapy is not required to establish, design, and/or deliver a program to maintain your current condition or prevent/slow further deterioration.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of physical therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve outpatient physical therapy.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary.The Plan denied your request. The Plan says the services are not medically necessary.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 services are not medically necessary. Our physician reviewer found the enrollee's ongoing care needs include respiratory care including ventilator management with tracheostomy care and supplemental oxygen, neurologic monitoring, surveillance laboratory studies, tube feeding, wound care, and therapy services. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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 forinpatient hospital care from October 4, 2019 through October 10, 2019.You asked the Plan to waive the copayment forinpatient hospital care. You say that you were misinformed by your plan and thought that seeing a specialist would cost you a $50 copayment.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 costsharing information (such as copayments, deductibles and coinsurance). Review of the file shows that you were admitted on October 4, 2019 and discharged on October 10, 2019. You were asked to pay a $395 copayment per day from October 4, 2019 through October 7, 2019, days 1-4 of your inpatient stay. There were no copayment charges from October 8, 2019, day 5 of your inpatient hospital care until your day of discharge October 10, 2019. Per your contract there is a $395 copayment per day required for days 1-4. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forinpatient hospital care from October 4, 2019 through October 10, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Febuxostat tablets.
You asked the Plan to pre-approve Febuxostat. You say that this is medically necessary. The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's Part D prescription drug plan.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Febuxostat tablets.
Benefits for Febuxostat may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe skilled nursing facility (SNF) service provided November 1, 2019 to November 9, 2019.You asked the Plan to pay forthe SNF services. You say that you feel that the plan should cover for the SNF services.The Plan denied your request. The Plan says medical necessity cannot be established for continued SNF level of coverage.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 pay for the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing and skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis and does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.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 SNF services have not been met.Therefore, we decided that the Plan does not have to pay forthe skilled nursing facility (SNF) service provided November 1, 2019 to November 9, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Part B injection provided on February
5, 2018.
You asked the Plan to waive the coinsurance for the Part B injection. You say that you should not be charged
an additional amount two years after the copayment amount had already been paid. The Plan denied your
request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20%
coinsurance for each Medicare-covered Part B drug.
You have been asked to pay $6.57 which is 20% of the allowed amount for the Part B injection. The allowed
amount is $32.87. ($32.87 x 20% = $6.57). The Part B injection falls within the "Medicare Part B prescription
drugs" 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 coinsurance for the Part B injection provided on
February 5, 2018.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an X-Ray examination provided on May 16, 2019.
You asked the Plan to pay for X-Ray examination. You say that you moved out of the Plan's service area but needed to have follow-up X-Rays. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this was foreseen care and not urgent/emergent in nature.
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care. 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 X-Ray examination. Our reviewer says that this service does not meet the Medicare criteria for urgent out-of-area care. Our physician reviewer found the need for this service was foreseeable before you left the Plan's service area. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of X-Ray examination have not been met. Therefore, we decided that the Plan does not have to pay for an X-Ray examination provided on May 16, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on November 25, 2019 by an out of network (OON) provider.You asked the Plan to pay for the OON services. You say that the services were provided in good faith according to the enrollee's needs.The Plan denied your request. The Plan says prior approval was not obtained for non-emergent services rendered in the enrollee's service area.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 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 medical services provided on November 25, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tier exception for Benlysta 200mg/ml autoinject (C9399).
You asked the Plan to pre-approve a tier exception for Benlysta 200mg/ml autoinject. You say that the tier exception is needed. The Plan denied your request. The Plan says Part B medications do not qualify for tier exceptions.
The Plan must follow Medicare rules. Medicare rules say that tiered cost-sharing means a process of grouping Part D drugs into different cost sharing levels within a Part D sponsor's formulary. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a tier exception for Benlysta 200mg/ml autoinject have not been met. Specifically, the requested drug is covered under Medicare Part B. This means that it is not eligible for a tier exception, as Medicare Part B Drugs are not subject to tier exceptions. Therefore, we decided that the Plan does not have to pre-approve a tier exception for Benlysta 200mg/ml autoinject (C9399).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe emergency room visit provided on November 26, 2019.You asked the Plan to waive the copayment forthe emergency room visit. You say that you believe the copayment should be waived because the two psychologists said he appeared to be okay. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $50 copayment for each covered emergency room visit worldwide. The enrollee has been asked to pay a $50 copayment for the emergency room visit. The emergency room visit falls within the "Emergency care" benefit category. The record shows services were received during the emergency room visit. 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 copayment forthe emergency room visit provided on November 26, 2019.