Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ten additional occupational therapy sessions for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says continued skilled occupational therapy is not reasonable and 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 the services. 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 generally not accepted as specific and effective therapy for the patient's condition. The enrollee has had extensive therapy and no longer requires the skills of a professional therapist to safely and effectively provide treatment. Services do not only need to be safely and effectively performed by a therapist, or under the supervision of a therapist. The enrollee's functional level can be met with assist of LTC staff and doesn't require ongoing therapy. The enrollee additionally has decreased carryover for therapy direction as demonstrated by the SLUMS score. The requested services are not part of a maintenance program and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve ten additional occupational therapy sessions for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided by an out-of-network provider on November 3, 2019. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the services received 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 rendering provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for laboratory services provided by an out-of-network provider on November 3, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an x-ray provided by a participating provider on January 15, 2020. 
 
You asked the Plan to waive the copayment for an x-ray. You say that you do not agree with these charges. The Plan denied your request. The Plan says the correct copayment has been 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 $20 copayment for outpatient diagnostic tests/x-rays.  
 
You have been asked to pay a $20 copayment for an x-ray. An x-ray falls within the outpatient diagnostic tests/x-rays 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 x-ray provided by a participating provider on January 15, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the laboratory work provided on February 10, 2020.
You asked the Plan to reduce the copayment for the laboratory work. You say that you are appealing the $162 charge. You say you believe the charge for this lab work should be $35. 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 $20 copayment per day, per provider, for in-network Medicare-covered lab services. You have been asked to pay a $20 copayment for the laboratory work. The laboratory work 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 reduce the copayment for the laboratory work provided on February 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on October 1, 2019. 
 
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use.  
 
The record shows that documentation submitted did not indicate the provider discussed the need for the billed supply code, so the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on October 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an annual wellness visit received on October 24, 2018. 
 
You asked the Plan to pay for the visit. You say that the statement would have been a lot less money if the office would have just seen your for the issue only, and didn't bill this as an annual visit. The Plan denied your request. The Plan says the claim was processed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that annual wellness visits are covered once per year. 
 
The file shows that you received an annual wellness visit on January 29, 2018. Based on this information, we decided that Medicare rules for coverage of the visit have not been met, as you would not be eligible to receive this same service again on January 29, 2019. Therefore, we decided that the Plan does not have to pay for an annual wellness visit received on October 24, 2018.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to waive the copayment for the ultrasound provided on January 16, 2020. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that there should be no copayment due to your age and history of smoking. The Plan denied your request. The Plan says that the copayment applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that enrollees must pay there is no coinsurance, copayment, or deductible for members eligible for this abdominal aortic aneurysm preventive screening. 
 
The Plan says you must pay $98.96 for the ultrasound. Based on the Plan contract, however, you cannot be asked to pay more than $0 for the ultrasound. The records show that the abdominal aortic aneurysm screening was ordered. Therefore, we decided that the Plan has to waive the copayment for the ultrasound provided on January 16, 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: 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 LTACH Admission is medically necessary. The Plan denied your request. The Plan says the enrollee can receive same services at the current level of care.
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 documentation does not support that the enrollee requires services that are not currently available. As LTACHs and acute care hospitals 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. 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 pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee has improved and is read to be transferred to the LTACH. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the enrollee's condition is still unstable and therefore the current level of care is appropriate. 
 
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 enrollee does not require services at the LTACH that are not available at the current acute care hospital where she is currently receiving care. Continued care in the short-term acute care hospital is appropriate until the enrollee is stable to transfer to a lower level of care such as an inpatient rehabilitation facility, sub-acute rehabilitation facility, or skilled nursing facility. 
 
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (G0249) provided on January 21, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the frequency limit has been exceeded. 
 
The Plan must follow Medicare rules. Medicare rules say that code G0249 is allowed once every 25 days.  
 
We looked at the file and Medicare rules. The records show that code G0249 was covered by the plan for date of service December 31, 2019. The requested services were provided less than 25 after the paid services, which exceeds the benefit limit. Based on this information, we decided that Medicare rules for coverage of G0249 have not been met. Therefore, we decided that the Plan does not have to pay for the services (G0249) provided on January 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist visit you had on February 14, 2020.
You asked the Plan to waive the copayment. You say that you have never had a copayment for these services. The Plan denied your request. The Plan says you are responsible for the copayment.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 copayment for each specialist office visit. Review of the file shows that you had a specialist visit on February 14, 2020. You have been asked to pay a $50 copayment for the visit. The visit falls within the physician services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the specialist visit you had on February 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided the Plan does not have to pay for compression stockings purchased out of network July 19, 2019.
You asked the Plan to pay for out of network purchases. You say that these compression stockings should be covered by the Plan. The Plan denied your request. The Plan says you did not have prior authorization to use and out of network provider for this purchase.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says durable medical equipment may require prior authorization and you should work the network providers to order in out of network equipment. You purchased compression stockings out of network. The Plan has network providers available who can provide compression stocking. The Plan did not pre-approve this purchase. We found no exception that would require the Plan to pay for these items. Therefore, we decided that the Plan does not have to pay for compression stockings purchased out of network on July 19, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary, as home is not a safe discharge location. The Plan denied your request. The Plan says under Medicare, this request is not medically necessary.
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 the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to be able to perform fifteen hours per week of rehabilitative services. The enrollee's care needs can be met at a lower level of care (ex. SNF/SAR). 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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for the transportation of portable x-ray equipment (CPT R0070) provided on January 28, 2020.
You asked the Plan to pay for the transportation of portable x-ray equipment. You say that the medical records provided support that the claim in dispute should be reprocessed for payment. The Plan denied your request. The Plan says that the CPT code in dispute has a PC/TC indicator of 3. The Plan also says that the place of service is inappropriate for procedure.
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. Specifically, the Plan has not substantiated their denial reasons. The Place of Service code shows that the services were performed in a skilled nursing facility (SNF). There is no clear citation that says the code in dispute is not payable when billed alone. There is no evidence that the code in dispute was billed with a modifier that prevents it from being covered. There is no supporting evidence or citation referenced that justifies the Plan's denial reason. Therefore, we decided that the Plan has to pay for the transportation of portable x-ray equipment (CPT R0070) provided on January 28, 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lidocaine 5% patch for the enrollee.
You asked the Plan to pre-approve the patch. You say that this is medically necessary. The Plan denied your request. The Plan says Medicare says Part B programs can only provide limited benefits for prescription drugs.
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 Lidocaine 5% patch for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says care could be received in another 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 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 you do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met at a lower level of care (ex. SNF/SAR). 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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Inpatient Hospital
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
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). You can find this rule at 42 CFR Section 422.111(a) and (b). 
 
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that enrollees must pay a $295 copayment per day for days 1-6 and a $0 copayment for days 7-90, for inpatient hospital care. Inpatient hospital care starts the day you are formally admitted to the hospital with a doctor's order. The day before you are discharged is your last inpatient day. You can find this information on page 76 of the Plan's 2020 (EOC).
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for drug testing provided on February 20, 2020. 
 
You asked the Plan to pay for drug test. You say that you conducted the laboratory testing ordered by the referring provider because it was deemed to be medically necessary. The Plan denied your request. The Plan says that the denial of payment for this service is correct, because the Plan was not provided with adequate records to understand why this testing was ordered. 
 
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. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. 
 
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 specify whether the ordering provider was in-network or outof-network with the Plan. The documentation does not include prior notice from the Plan that this testing would not be covered. Without this information, we cannot determine whether the lab order made constitutes plandirected care. Therefore, the Plan has not shown that its decision to deny payment for this test is correct or justified according to Medicare rules. Therefore, we decided that the Plan has to pay for drug testing provided on February 20, 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.