Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre 14 day sensor.
You asked the Plan to pre-approve a Freestyle Libre 14 day sensor. You say that the item is necessary. The
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been
met.
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 a Freestyle Libre 14 day sensor. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found in order for you to meet criteria for a Continuous Glucose Monitor (CGM),
you must be taking insulin and take insulin multiple times per day. The documentation does not show that this
is the case; furthermore, you are on 2 medications for diabetes mellitus (DM) that do not cause low blood
glucose and the overall control seems excellent at 6.2% a1c. It is not documented why it is particularly
important for you to use a libre vs a glucometer. Hence, the libre does not meet medical necessity criteria.
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 Freestyle Libre 14 day sensor have not been met. Therefore, we decided that
the Plan does not have to pre-approve a Freestyle Libre 14 day sensor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a specialist office visit provided on November 6, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for a specialist office visit. You say that you have had this doctor for years. You say that you changed plans and did not know he was considered out-of-network. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that there are in-network providers available 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 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 a specialist office visit provided on November 6, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve acute inpatient rehabilitation facility care. You say that an inpatient
rehabilitation facility admission is medically necessary. The Plan denied your request. The Plan says you do
not meet criteria for coverage of an inpatient rehabilitation facility admission.
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 inpatient rehabilitation facility care.
Our reviewer says that you do not meet criteria for coverage of an acute inpatient rehabilitation facility
admission. Our physician reviewer found that you are medically stable as there is no evidence of complex
medical issues that require monitoring by an inpatient physician or a need for acute rehabilitation nursing care.
Therefore, an inpatient rehabilitation facility admission is not medically necessary based on your current
functional 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 inpatient rehabilitation facility care have not been met. Therefore, we decided
that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and
services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe chest x-ray rendered on November 6, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 71045 is not separately payable.The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.The provider submitted a claim for procedure codes 71045 and 74022. Code 71045 is a column II code with a modifier indicator of 1 when billed with column I code 74022. Code 71045 was not billed with an appropriate modifier to allow for separate payment.Therefore, we decided that the Plan does not have to pay forthe chest x-ray rendered on November 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided on July 16, 2019 by an out of network (OON) provider.
You asked the Plan to pay for skilled nursing services. You say that you rely on authorizations obtained by the facility. You say that you provide services that are medically necessary. 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 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 July 16, 2019 by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ER visit at the Hospital on July
31, 2019.
You asked the Plan to waive the copayment for an ER visit. You say that you went to an urgent care facility
and disagree with 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.
The medical records show that you had an ER visit on July 31, 2019. Therefore, you are responsible to pay the
$90 copayment.
You have been asked to pay a $90 copayment for an ER visit. An ER visit 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 an ER visit at the
Hospital on July 31, 2019.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your
request. The Plan says that based on the documentation provided, coverage criteria has not been met.
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 SNF care. Our reviewer says that the
services are medically necessary. Our physician reviewer found you require both daily skilled therapy and
nursing services. Your condition would be expected to deteriorate with services provided on a less than daily
basis. You had previously been treated at the SNF level. There is a reasonable expectation of a reduction in
burden of care with a goal of a successful return to the community through the SNF level care being requested.
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 care have been met. The Plan must continue coverage for the SNF skilled
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing
facility (SNF) care.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for office visits from October 8, 2018 to December 20, 2018.
You asked the Plan to waive the copayments for office visits. You say that for an in-network provider there is a
$30 copayment, not $50 copayment for these services. The Plan denied your request. The Plan says the
copayment amounts you are being charged are correct.
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 $50
copayment for each specialist office visit. There were 3 visits, resulting in a total copayment obligation of
$150.
You have been asked to pay $50 copayment for each office visit. Office visits fall within the
Physician/Practitioner Services, Including Doctor's Office Visits 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 copayments for office visits from October 8, 2018 to December 20, 2018.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wireless pulmonary artery pressure sensor for the enrollee.
You asked the Plan to pre-approve the sensor. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a supported procedure because there is not enough research showing that it would be helpful.
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 sensor. Our reviewer says that the requested sensor is not considered medically reasonable and necessary in this case. Our physician reviewer found in this circumstance therapy change based on data obtained from a CardioMEMs device has been demonstrated in only one trial to help reduce hospital readmission compared to standard medical therapy. Moreover, concerns have been raised about potential bias in this trial calling into question the results (reference 2). Therefore the efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and not recommended in current guidelines for the treatment of heart failure. Medicare coverage criteria are not met since the device should still be considered experimental or 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 sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a wireless pulmonary artery pressure sensor for the enrollee
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye exam (92134) and ophthalmic imaging provided on November 5, 2019.
You asked the Plan to waive the copayment for the vision and diagnostic services. You say that the exact same tests were taken months before and the copay was waived due to improper coding and feel that due to the aggravation and phone calls you've had to deal with the copayments should be waived. The Plan denied your request. The Plan says the correct cost share was correctly 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 $20 per day for Medicare covered tests and $45 for 1 annual routine eye exam. You have been asked to pay $65 for the vision and diagnostic services. 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 eye exam (92134) and ophthalmic imaging provided on November 5, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the physical therapy provided from
October 1, 2019 to November 19, 2019.
You asked the Plan to waive the copayments for the physical therapy visits. You say that you were told the
therapy after your back surgery would be covered. You say you are on a fixed income. 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 $40
copayment for in-network Medicare-covered physical, language and speech therapy services.
You have been asked to pay a $40 copayment for each of the physical therapy visits. The physical therapy
visits fall within the "Outpatient rehabilitation 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 copayments for the physical therapy provided from October 1, 2019 to November 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered to you by a chiropractor on November 15, 2019 to November 21, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered when performed by a chiropractor.
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. The file shows that the provider submitted claims for procedure codes 97012 (mechanical traction therapy), 97010 (hot or cold packs therapy), and 97014 (electrical stimulation therapy). Therefore, we decided that the Plan does not have to pay for the services rendered to you by a chiropractor on November 15, 2019 to November 21, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy visits.You asked the Plan to pre-approve the additional physical therapy visits. The Plan denied your request. The Plan says the enrollee does not meet the criteria necessary for continued physical therapy services. The progress notes document no improvement to the enrollee's level of pain, ability to do more activities, and the ability to walk or dress. The enrollee has dementia that interferes with her ability to recall home exercises. The Plan recommends a follow-up appointment with her PCP and have a home safety evaluation.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 additional physical therapy visits. Our reviewer says that skilled services are not reasonable and medically necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that the documentation does not reveal the therapy services are of a level of complexity and sophistication or the condition of the enrollee shall be such that the therapy services required can be safely and effectively performed only by a therapist, or under the supervision of a therapist. The enrollee has had extensive therapy and continues to have fair rehabilitation potential has severe pain. The enrollee's functional level does not require ongoing skills of a therapist to treat the illness or injury. The services can be carried out by non-skilled personnel. The request for an additional therapy services is not reasonable and medically necessary as the patient can transition with a non-skilled caregiver to assist (due to dementia) to an independent home exercise 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 the additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on November 14, 2019 to the enrollee by an out of network (OON) provider. You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by a non-participating provider without 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 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 medical services provided on November 14, 2019 to the enrollee by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from August 7, 2019 through August 9, 2019.
You asked the Plan to waive the copayment for inpatient hospital care. You say that the admission was due to complications from chemo/radiation treatment and were ordered by your oncologist. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file shows that you were admitted on August 7, 2019 and discharged on August 9, 2019. You were asked to pay a $285 copayment per day from August 7, 2019 through August 8, 2019, days 1-2 of your inpatient hospital care. You were discharged on August 9, 2019 and there was no copayment charge for the day of discharge. Per your contract there is a $285 copayment per day required for days 1-7. 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 inpatient hospital care provided from August 7, 2019 through August 9, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy provided on November 6,
2019.
You asked the Plan to waive the copayment for the colonoscopy. You say that there should be no different in
the cost of this colonoscopy from a colonoscopy in which no polyps are removed. You say you should be
charged the same as a routine colonoscopy. 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 $400
copayment for in-network Medicare-covered outpatient hospital surgery services.
You have been asked to pay a $400 copayment for the colonoscopy. The colonoscopy falls within the
"Outpatient hospital services" benefit category. The record shows you had polyps removed which makes the
colonoscopy diagnostic in nature.
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 colonoscopy provided on November 6, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent hospital care (CPT Code 99233) provided to the enrollee on September 24, 2019. 
 
You asked the Plan to pay for the services. You say that the CPT code 99233 was denied as missing/incomplete/invalid/inappropriate place of service. You state you are resubmitting the claim with patient encountered for schizophrenia for which the provider has performed inpatient evaluation and management services. You state the given procedure codes 99222 is appropriate for place of service (POS) 21. The Plan denied your request. The Plan says the patient was not in an inpatient status for this date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 
 
The facility claim was billed and paid as outpatient. On September 24, 2019 the patient was still an outpatient. An observation service should have been billed, not the inpatient code with the inpatient POS. 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 subsequent hospital care (CPT Code 99233) provided to the enrollee on September 24, 2019.