Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), the prophylaxis (D1110), and the bitewing x-rays (D0274) provided on September 10, 2019.You asked the Plan to pay forthe dental services. You say that you do not agree with the member responsibility on the claims for your visit to get your dentures cleaned.The Plan denied your request. The Plan says dental services that you receive out of network are not covered. The Plan also says that the provider in this case is not a network provider.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 dental services you received are not covered when you receive them out of network.Therefore, we decided that the Plan does not have to pay forthe periodic oral evaluation (D0120), the prophylaxis (D1110), and the bitewing x-rays (D0274) provided on September 10, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF).You asked the Plan to pre-approvethe SNF admission. You say that it is felt that care in the SNF would be the best option.The Plan denied your request. The Plan says the enrollee does not need skilled services on a daily basis.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 the SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the hospital on 1/29/2020 with chronic low back pain and compression fractures. She wears a back brace when out of bed and is mostly minimal/contact guard assist for care. She is non-toxic. She has no complex wound care or skilled therapy or nursing needs.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 admission have not been met.Therefore, we decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe percutaneous vertebral augmentation provided on June 7, 2019.You asked the Plan to waive the copayment forthe percutaneous vertebral augmentation. You say that you were informed by the agent that signed you up that you would not have to pay for anything.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 $295 copayment for outpatient hospital surgery services.You have been asked to pay a $295 copayment for the percutaneous vertebral augmentation. The percutaneous vertebral augmentation falls within the "Outpatient surgery, including 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 obligationyou agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment forthe percutaneous vertebral augmentation provided on June 7, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Planhasto pre-approvea CT scan of the abdomen/pelvis.You asked the Planto pre-approvethe CT scan. You say that the enrollee has not had a CT scan since May of 2019 and is due for reassessment.The Plandenied your request. The Plansaysthatthis was already approved and the approval expired. It is not known if the imaging was done before the approvals expiration so this cannot be authorized. The plan then did not meet the timeliness guidelines and did notreview the appeal documentation.The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the CT scan. Our reviewer says that the requested imaging is medically necessary. Our physician reviewer found the enrollee is a patient with low grade neuroendocrine cancer with abdominal disease. Per the NCCN Guidelines, this reimaging is reasonable and necessary to assess disease status.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 CT scan have been met.Therefore, we decided that the Planhas to pre-approvea CT scan of the abdomen/pelvis.If the Plandoes 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 toreview. The Plan has to show us the mistake and/orsend 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex interspinous device.You asked the Plan to pre-approvethe requested device. You say that the enrollee will benefit from a less invasive approach.The Plan denied your request. The Plan says medical guidelines and peer reviewed literature do not support the device over a lumbar laminectomy.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 requested device. Our physician reviewer found that the requested device is experimental. More research is needed to prove the efficacy of the device. Therefore, the requested service is 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 have not been met. Therefore, we decided that the Plan does not have to pre-approvea Vertiflex interspinous device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing care provided on August 8, 2019 by out of network provider. You asked the Plan to pay forskilled nursing care. You say that STCCS is contracted to work with Sorrento. You say that you must see the patient with no opportunity to pick on grounds of insurance status.The Plan denied your request. The Plan says no prior authorization was 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 caseis 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 forskilled nursing care provided on August 8, 2019 by out of network provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for subsequent hospital care (99231) provided on May 7, 2019.You asked the Plan to pay for the subsequent hospital care. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that the visit was billed by the same provider within the 15734s post-operative period.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.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 forward the claim or evidence of the date of service and provider of the initial procedure. Therefore, we decided that the Plan has to pay for subsequent hospital care (99231) provided on May 7, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe SNF stay provided from August 1, 2019 to August 6, 2019.You asked the Plan to waive the copayment forthe SNF stay. You say that that you were not aware there would be a copayment for the additional time you requested for the SNF stay. You say this is a financial hardship. 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 a $0 copayment per day, days 1-20 and a $172 copayment per day, days 21-100 for each in-network SNF stay. You have been asked to pay a $860 copayment for the SNF stay. The SNF stay falls within the "Skilled nursing facility (SNF) care" benefit category. The record shows your SNF stay was a total of 25 days. You had a $0 copayment for days 1-20 and a $172 copayment per days for days 21 to 25. ($172x 5 = $860).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 forSNF stay provided from August 1, 2019 to August 6, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.You asked the Plan to pre-approveSNF services. You say that the member's treatment would not be safe at a homeless shelter.The Plan denied your request. The Plan says that the enrollee's needs could be met at the extended care facility and do not require a SNF level of care.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 todetermine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF 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 SNF services have not been met.Therefore, we decided that the Plan does not have to pre-approveskillednursing facility (SNF) services for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvelong term acute care hospital (LTACH) services.You asked the Planto pre-approvethe LTACH services. You say that the enrollee would benefit from LTACH care.The Plandenied your request. The Plansaysthe enrollee can remain in the current facility.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 the patient is currently undergoing treatment at an ACH for end-stage pulmonary disease. The enrollee is not intubated/ventilated. 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 LTC needs.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 Plandoes not haveto pre-approvelong term acute care hospital (LTACH) services
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvechiropractic spinal decompression treatment.You asked the Plan to pre-approvechiropractic spinal decompression treatment. You say that this should be covered as it is your only option.The Plan denied your request. The Plan says this service is not covered by Medicare or the Plan.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine.Therefore, we decided that the Plan does not have to pre-approvechiropractic spinal decompression treatment.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital care (99223 and 99232) provided from May 20, 2019 to May 22, 2019.You asked the Plan to pay forhospital care. You say that these services should be paid.The Plan denied your request. The Plan says the services billed on this claim duplicate services previously paid on other claims.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 99223 has a column 1/column 2 relationship with code 99222, which was previously paid for date of service May 20, 2019, and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. The rules also say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. In this case, 99232 was previously billed by the same provider for date of service May 22, 2019. It has been determined that these claim lines are duplicates.Therefore, we decided that the Plan does not have to pay forhospital care (99223 and 99232) provided from May 20, 2019 to May 22, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe SNF stay provided from July 18, 2019 through July 29, 2019.You asked the Plan to waive the coinsurance forthe SNF stay. You say that you chose this facility because your wife had a positive experience. You say that you were informed the provider may not be in-network.The Plan denied your request. The Plan says the coinsurance 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 20% of the cost for days 1-100 at an out-of-network skilled nursing facility.You have been asked to pay $1,129.09, which is 20% of the allowed amount for the SNF stay. The allowed amount is $5,645.47 (20% x $5,645.47 = $1,129.09). The SNF stay falls within the "Skilled nursing facility (SNF) care" benefit category. The records show that the provider is out-of-network. 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 forthe SNF stay provided from July 18, 2019 through July 29, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forinpatient hospital services provided August 5, 2019 to August 8, 2019.You asked the Plan to pay forthe inpatient services. You say that the services were medicallynecessary.The Plan denied your request. The Plan says a correct claim is needed to process payment.The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediaryor carrier sufficient information to determine whether payment is due and the amount of payment. We looked at the file and Medicare rules. The provider did not provide the complete medical record to the plan to determine if the claim is supported. Basedon this information, we decided that Medicare rules for coverage of the inpatient services have not been met.Therefore, we decided that the Plan does not have to pay forinpatient hospital services provided August 5, 2019 to August 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on September 25, 2019.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 nota network provider with the Plan. 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 physician's services providedon September 25, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF).You asked the Plan to pre-approveadmission to a skilled nursing facility (SNF). You say that the requested admission to a SNF is medically necessary.The Plan denied your request. The Plan says the requested admission to a SNF does not meet criteria.The Plan must follow Medicare rules. The rules say thatMedicare 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 admission to a skilled nursing facility (SNF). Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is diagnosed with sepsis due to escherichia coli (E. coli). Per a 2/5/20 speech therapy (ST) note she is on a mechanical soft nectar thick diet. Her cognitive testing revealed severe cognitive impairment. Per a 2/10/20 document she is a lift transfers, can walk in parallel bars with 2 person assist but was non ambulatory on units. She knows her name but not where she is. Physical therapy (PT) and occupational therapy (OT) report easy fatigue and lift transfers. A 2/10/20 medical note reveals her blood pressure is stable off Lopressor. She is status post loop monitor to evaluate for atrial flutter but felt less likely cause of cerebral vascular accident (CVA) and more indicative of hypertension. Her oral intake is noted with dysphagia and overlying delirium. Dietary consult considered and medications were reviewed. She had a urine culture with staph sensitive to Bactrim. Renal function and potassium stable enough to handle. Her coronary artery disease is stable. This enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment. The enrollee does not have a tracheostomy tube, enteral feedings, complex wound care or other SNF level skilled nursing need. This enrollee's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment at a SNF level. The enrollee does not require these skilled nursing or skilled therapy services (or a combination of these services) on a daily basis. As a practical matter this enrollee does not require the necessary services on 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 admission to a skilled nursing facility (SNF) have not been met.Therefore, we decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveSaxenda 18mg/3ml pen (J3490).You asked the Plan to pre-approveSaxenda 18mg/3ml pen. You say that the medication is necessary.The Plan denied your request. The Plan says the enrollee has a medical only policy which does not includePart D prescription coverage, therefore the criteria for self-administered drug coverage has not been met.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administereddrugs 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-approveSaxenda 18mg/3ml pen (J3490).Benefits for Saxenda 18mg/3ml penmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Entresto 49-51mg tablet medication.You asked the Plan to pre-approvethis medication. You say that this medication is medically necessary for the enrollee as she has a diagnosis of chronic congestive heart failure. Additionally, the enrollee has been takingthis medication since November and has been noticing an improvement. The Plan denied your request. The Plan says the requested medication is denied as a benefit exclusion.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approvethe Entresto 49-51mg tablet medication.Benefits for this medicationmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.