Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient hospital services provided on November 4, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the outpatient hospital services. You say that the services were medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
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 the outpatient hospital services provided on November 4, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion Spacer.
You asked the Plan to pre-approve the Vertiflex Superion Spacer. You say that you would like reconsideration because this device is medically necessary. The Plan denied your request. The Plan says this service is experimental.
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 Vertiflex Superion Spacer. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex Spacer is experimental and more research is needed to show its safety and efficacy. 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 Vertiflex Superion Spacer have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion Spacer.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient surgical procedure provided from November 5, 2020, to November 6, 2020.
You asked the Plan to waive the copayment for an outpatient surgical procedure. You say that you suffered from complications and feel that you should not be responsible for the charges. 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 $325 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You have been asked to pay a $325 copayment for an outpatient surgical procedure. An outpatient surgical procedure 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 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 outpatient surgical procedure provided from November 5, 2020, to November 6, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that you meet LTACH admission criteria. The Plan denied your request. The Plan says the requested 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 requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found that there is no documentation provided necessitating admission to a LTACH. You are receiving appropriate care at the present acute care hospital. You do not require services at the LTACH that are not available at the acute care hospital where you are currently receiving care. There are no services available at the LTACH that you require that are not available at the health care setting being offered by the Plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for your diagnosis and condition.

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 the LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair controller upgrade, power wheelchair electric connection, and a power wheelchair harness upgrade. You asked the Plan to pre-approve a power wheelchair controller upgrade, power wheelchair electric connection, and a power wheelchair harness upgrade. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested items are not a covered benefit. The Plan must follow Medicare rules. Medicare rules say that power wheelchair accessories are only covered for certain indications.
We looked at the file and Medicare rules. Review of the file shows that the approved power options come with their own switches. The requested items exceed your needs and are not covered. Based on this information, we decided that Medicare rules for coverage of a power wheelchair controller upgrade, power wheelchair electric connection, and a power wheelchair harness upgrade have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair controller upgrade, power wheelchair electric connection, and a power wheelchair harness upgrade.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on September 2, 2020, by an
OON provider.
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid.
You say that this all happened during the shutdown. The Plan denied your request. The Plan says prior
authorization was not obtained by a participating provider.
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 physician services provided on September 2, 2020,
by an OON provider.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve CardioMEMS.
You asked the Plan to pre-approve CardioMEMS. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the requested services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 CardioMEMS. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has recurrent episodes of congestive heart failure (CHF), peripheral edema and Class III CHF. The enrollee has been hospitalized in the past year and has had a number of requests by physicians for acute hospitalization more recently which the enrollee has declined. The enrollee is on a complex medical regimen for heart failure and remains severely symptomatic despite continued titration of medical therapy and close clinical follow-up. CardioMEMS monitoring of fluid status has been shown in enrollees with persistent Class III CHF despite guideline directed medical therapy and close clinical follow-up to improve symptoms and need for re-hospitalizations. Although not indicated in every situation, in enrollees on complex regimens who are not responding to regular follow-up and management, who have persistent Class III symptoms, and who have been hospitalized in the past year for CHF, close fluid status monitoring using the Cardiomems device has published randomized data and expert opinion to support its use and is FDA approved for this indication. Therefore, the enrollee meets criteria for the requested 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 CardioMEMS have been met. Therefore, we decided that the Plan has to pre-approve CardioMEMS.
We note that the plan is stating that these services are only covered when the enrollee is in a Medicare approved study. However, our physician reviewer has found that the requested services are FDA approved and should be covered for the enrollee.
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: Testing
Decision: Favorable

We decided that the Plan has to waive the copayment for a colonoscopy screening provided on September 25, 2020.
You asked the Plan to waive the copayment for a colonoscopy screening. You say that you received a colonoscopy screening and should not be responsible for the charges. The Plan denied your request. The Plan says that 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. Your contract with the Plan says that there are no cost-sharing charges for colorectal cancer screenings. The medical records show that you had a colonoscopy screening on September 25, 2020. Colonoscopy screenings are covered once every 48 months. There is no indication in the record that this benefit was exhausted. Furthermore, the medical records did not show that any polyps were removed. Therefore, you cannot be charged a copayment. The Plan says you must pay a $300 copayment for a colonoscopy screening. Based on the Plan contract, however, you cannot be asked to pay for a colonoscopy screening. Therefore, we decided that the Plan has to waive the copayment for a colonoscopy screening provided on September 25, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided on November 30, 2020 by an out of network (OON) provider.
You asked the Plan to pay for skilled nursing services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by a participating provider or provided at a participating facility.
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 skilled nursing services provided on November 30, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye exam, deluxe frames, anti-reflective lens coating, and progressive lenses rendered on October 27, 2020.
You asked the Plan to pay for these services. You say that you overpaid for the services. The Plan denied your request. The Plan says the claim was processed correctly.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers up to $115 for routine vision services. Enrollees must pay for additional upgrades to eyeglasses. We looked at the file and the Plan's rules. The file shows that you received an eye exam, deluxe frames, anti-reflective lens coating, and progressive lenses on October 27, 2020. The Plan covered the eye exam and deluxe frames. The anti-reflective coating and progressive lenses are additional non-covered upgrades. Further payment is not covered by Medicare or your supplemental vision benefit.
Therefore, we decided that the Plan does not have to pay for the eye exam, deluxe frames, anti-reflective lens coating, and progressive lenses rendered on October 27, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for nurse practitioner services and laboratory services provided on July 24, 2020 and July 25, 2020.
You asked the Plan to pay for the nurse practitioner services and laboratory services. The Plan denied your request. The Plan says members must receive care from a network provider and in most cases, care received from an out-of-network provider will not be covered, except for emergency care or urgently needed service and needed medical care that Medicare requires our plan to cover and the providers in our network cannot provide this care (authorization is required).
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 did not pre-approve the nurse practitioner services and laboratory services. 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 nurse practitioner services and laboratory services provided on July 24, 2020 and July 25, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion Spacer.
You asked the Plan to pre-approve the Vertiflex Superion Spacer. You say that you would like reconsideration because this device is medically necessary. The Plan denied your request. The Plan says this device is experimental.
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 Vertiflex Superion Spacer. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollee's medical condition. 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 Vertiflex Superion Spacer have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion Spacer.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan provided by a participating
provider on October 26, 2020.
You asked the Plan to waive the copayment for a CT scan. You say that you do not agree with this second
copayment. 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 $150
copayment for outpatient diagnostic tests/CT scan.
You have been asked to pay a $150 copayment for a CT scan. The correct copayment has been applied to the
diagnostic imaging that was provided. A CT scan falls within the outpatient diagnostic tests/CT scan 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 a CT scan provided by a participating provider
on October 26, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve Arthrocentesis (20605, 20606, 20610).

You asked the Plan to pre-approve Arthrocentesis (20605, 20606, 20610). You say that Arthrocentesis is medically necessary. The Plan denied your request. The Plan says that the procedures for shoulder pain are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 Arthrocentesis (20605, 20606, 20610). Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has had prior shoulder injections which have provided him with 6 months of pain relief. The enrollee has had both physical therapy and occupational telemedicine visits. The request is medically reasonable and 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 Arthrocentesis (20605, 20606, 20610) have been met. Therefore, we decided that the Plan has to pre-approve Arthrocentesis (20605, 20606, 20610).

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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the air ambulance services (A0435) provided on September 27, 2019.
You asked the Plan to pay for the air ambulance services. You say that you would like reconsideration because the air transport was medically necessary to return you to the United States in order for you to receive needed medical care. The Plan denied your request. The Plan says you were in stable condition upon discharge from the hospital.
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your medical condition is such that transportation by ground ambulance is not appropriate. 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 air ambulance services. Our reviewer says that this request for ambulance services will be considered not medically necessary at this time based on the provided records. Our physician reviewer found the documentation did not show that you required expertise or special equipment during transportation. In this case, nonemergent transportation would have sufficed.
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 air ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for the air ambulance services (A0435) provided on September 27, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care provided on December 3, 2020.
You asked the Plan to waive the copayment for emergency care. You say that you cannot afford the charges. 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 December 3, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasounds provided on January 10, 2020.
You asked the Plan to waive the copayment for the ultrasounds. You say that you had a mammogram and were informed you needed to have an ultrasound. You say that you already paid your copayment last time. 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 $100 copayment for diagnostic procedures and tests at an in-network outpatient hospital facility. You have been asked to pay $56.07, which is less than the standard $100 copayment for the ultrasounds. The ultrasounds fall 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 ultrasounds provided on January 10, 2020.