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

We decided that the Plan does not have to waive the copayments for outpatient rehabilitation services provided from September 17, 2019 to October 15, 2019. You asked the Plan to waive the copayments for outpatient rehabilitation services. You say that you disagree with the pre-surgery physical therapy charges because the enrollee can't afford them and they were unnecessary. The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $40 copayment for outpatient rehabilitation services. The enrollee received outpatient rehabilitation services from September 17, 2019 to October 15, 2019 for a total of 9 visits. Therefore, the total amount the enrollee owes is: $40 (copayment) x 9 (visits) = $360. The enrollee has been asked to pay the total copayment amount of $360 for outpatient rehabilitation services. Outpatient rehabilitation services fall within the outpatient rehabilitation services benefit category. 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 copayments for outpatient rehabilitation services provided from September 17, 2019 to October 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided on February 3, 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 approved for payment. The Plan denied your request. The Plan says the treating facility is out-of-network. The Plan says that 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 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 skilled nursing services provided on February 3, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lantus Solostar 100 unit/ml for the enrollee. You asked the Plan to pre-approve the drug. 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 Lantus Solostar 100 unit/ml for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Livalo.You asked the Plan to pre-approve Livalo. You say that the enrollee is controlled on Livalo. The Plan denied your request. The Plan says the requested drug is not covered under the Part B 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 Livalo.Benefits for Livalo 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Detrol LA. You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says this plan has Part A and Part B coverage, with no Part D coverage. 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 Detrol LA.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on January 6, 2020 by an out-of-network provider. You asked the Plan to pay for the dental services. You say that you were misinformed on the provider participating status. The Plan denied your request. The Plan says there was no information that you or the provider contacted the plan prior to the services rendered. 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 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. Furthermore, dental codes D4341, D4381, D4921, D9630 are not listed as covered services under your EOC. Therefore, we decided that the Plan does not have to pay for the dental services provided on January 6, 2020 by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and related services provided on January 13, 2020 by an out of network (OON) provider. You asked the Plan to pay for these OON services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit. 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 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 office visit and related services provided on January 13, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Methylprednisolone (J7509) for the enrollee. You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says given the current information, this drug is not covered for the enrollee's condition. 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 Methylprednisolone (J7509) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the pigmented lesion assay provided on December 11, 2019. You asked the Plan to pay for the provided services. You say that the test identifies gene expression risk factors for melanoma in clinically suspicious lesions. The Plan denied your request. The Plan says the testing does not eliminate the need to perform a skin examination nor testing should abnormal results be detected. 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 pay for the provided services. Our physician reviewer found that the enrollee has a past medical history of hypertension, hyperlipidemia, prostate cancer and squamous cell skin cancer. The enrollee presented to dermatology with multiple pigmented lesions of uncertain behavior. The documentation does not show that the provided testing was medically reasonable and necessary to treat the enrollee's condition. The DermTech Pigmented Lesion Assay is experimental and investigational. 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 provided services have not been met. Therefore, we decided that the Plan does not have to pay for the pigmented lesion assay provided on December 11, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for a home visit (99348) provided on July 18, 2019. You asked the Plan to pay for a home visit. You say that this service was needed due to a recent hospitalization. The Plan denied your request. The Plan says that this was 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 pay for a home visit. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found one of the greatest risks for hospitalization is recent hospitalization. The documentation provided documented several important issues that can prevent repeat hospitalization including monitoring response to medication and going over safety within the home. Falls are a common cause among the chronically ill for hospitalization. This visit documented vital signs in addition to important preventative measures to prevent costly repeat hospitalization. The visit documentation justifies the charges and meets criteria for coverage. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a home visit have been met. Therefore, we decided that the Plan has to pay for a home visit (99348) provided on July 18, 2019. 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 acute inpatient rehabilitation facility (IRF) admission and services. You asked the Plan to pre-approve IRF care. You say that that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says the records do not meet the coverage criteria. The enrollee's needs can be met at a lower level of care. 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 complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's current medical status does not require intensive physician or nursing oversight in an IRF. The enrollee may benefit from additional multiple therapies, however the enrollee's functional level does not require or indicate that this therapy must be in an IRF with an intensive level program. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an IRF admission and services. You asked the Plan to pre-approve IRF care. You say that you have had a decline in function since going home despite home health services. The Plan denied your request. The Plan says you do not meet criteria for an IRF admission and services. The Plan must follow Medicare rules. The rules say that an 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 that you are generally medically stable and no other records of physical therapy (PT), occupational therapy (OT) assessments, treatments or progress were made available. There is no evidence of complex medical issues that require monitoring by an inpatient PMR physician three times per week or need for acute rehabilitation nursing care. Inpatient rehabilitation may be covered when the enrollee needs an intensive rehabilitation program with a team of specialized healthcare professionals, and supervision by providers that specialize in rehabilitation, the enrollee needs supervision by a provider who specializes in rehabilitation, the enrollee needs and can do 3 or more hours of PT, OT, speech therapy per day, at least 5 days per week. Based on review of the available records, the you do not meet criteria for coverage for an IRF admission. 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 an IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on January 29, 2020. You asked the Plan to waive the copayment for the office visit. You say that no labs were included. You say that you do not owe the copayment. 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 $10 copayment for in-network, Medicare-covered primary care physician services. You have been asked to pay a $10 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show that you were treated for hyperlipidemia during the office visit. 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 office visit provided on January 29, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. You asked the Plan to pre-approve IRF care. You say that an admission to an IRF is medically necessary. The Plan denied your request. The Plan says admission to an IRF does not meet criteria. 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 that the enrollee was medically stable with no evidence of need for supervision by PMR physician or needs acute rehabilitation nursing care. The enrollee may benefit from further physical therapy and occupational therapy but the enrollee does not require an intensive therapy program. The enrollee's rehabilitation needs can be met at a lower intensity setting such as in a skilled nursing facility. An IRF admission is not medically necessary based on the patient's current functional mobility status and medical stability. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance ride provided on January 13, 2020. You asked the Plan to waive the copayment for the ambulance ride. You say that you have never had to pay for an ambulance ride before. 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 $250 copayment for Medicare-covered ambulance services. Cost sharing applies for each one-way trip. You have been asked to pay a $250 copayment for the ambulance ride. The ambulance ride falls within the "Ambulance 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 ambulance ride provided on January 13, 2020. Our decision is only about the 2020 service. If you have any questions about prior years billing, please contact the plan directly.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (Q5001, S9131) provided on November 4, 2019. You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are not payable. The Plan must follow Medicare rules. Medicare rules say that a treatment authorization code is required on RAPs with "From" dates before January 1, 2020. The rules also say that a status indicator of "I" under the Physician Fee Schedule indicates that the code in question is not valid for Medicare purposes. We looked at the file and Medicare rules. The claim for code Q5001 was billed without a treatment authorization code. This code is required for the claim to be processed. Additionally, code S9131 is assigned a status indicator of "I" under the Physician Fee Schedule. This means that this code is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services (Q5001, S9131) provided on November 4, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the trastuzumab injections provided from January 28, 2020 to February 18, 2020. You asked the Plan to waive the coinsurance for the injections. You say that the enrollee should not have to pay this much. The Plan denied your request. The Plan says that the claim 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). The enrollee's contract with the Plan clearly says that the enrollee must pay a 20% coinsurance for Medicare Part B prescription drugs. The enrollee has been asked to pay a 20% coinsurance for the injections. The injections fall within the Medicare Part B prescription drugs benefit category. This means that the enrollee has been asked to pay the correct amount based on the enrollee's contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay when she enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the trastuzumab injections provided from January 28, 2020 to February 18, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a low dose CT scan received on February 5, 2020. You asked the Plan to pay for the scan. You say that this should be paid for. The Plan denied your request. The Plan says this should not be performed more than once within a 12-month period. 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, the CPT Code Manual definition of code G0297 is "Low dose CTscan (LDCT) for lung cancer screening." We find that CPT code G0297 is not supported in the medical record. Specifically, this code is being billed less than one year after the previous scan was received. The code was previously billed and approved on August 27, 2019. Based on this information, we decided that Medicare rules for coverage of the scan have not been met. Therefore, we decided that the Plan does not have to pay for a low dose CT scan received on February 5, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on December 29, 2019. You asked the Plan to waive the copayment for the ambulance transport. You say that you need help paying this bill. The Plan denied your request. The Plan says that the copayment is due regardless of your financial circumstances. 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 per ambulance trip. You have been asked to pay a $150 copayment for the ambulance transport. The ambulance transport falls within the per ambulance trip 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 ambulance transport provided on December 29, 2019.