Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the enrollee from June 18, 2021, to July 13, 2021.
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee was at a baseline level of function and did not receive skilled therapy.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 pay for the services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found at the time of discharge from the hospital, the enrollee had stabilized medically. The enrollee did not require any skilled nursing or rehab services on a daily basis at an inpatient level of care. She was not expected to make measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent deterioration with mobility or activities of daily living. As a practical matter, the enrollee did not require any skilled services on an inpatient basis, at a SNF level of care at the time of discharge from the hospital. 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 pay for skilled nursing facility (SNF) services provided to the enrollee from June 18, 2021, to July 13, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a Left Atrial Appendage Closure (LAAC) procedure (33340).
You asked the Plan to pay for the LAAC procedure. You say that the services are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that LAAC is only covered as a second line therapy to oral anticoagulants. 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 LAAC procedure. Our reviewer says that the procedure is not medically necessary. Our physician reviewer found a progress note from June 2021 indicates that the enrollee is on warfarin without complications, has not had any bleeding issues and has had no falls. The records do not show that the enrollee is unable to tolerate anticoagulants. 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 LAAC procedure have not been met. Therefore, we decided that the Plan does not have to pay for a Left Atrial Appendage Closure (LAAC) procedure (33340).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the ankle/foot brace you received on May 28, 2021.
You asked the Plan to waive the coinsurance for the ankle/foot brace. You say that you do not believe you should have to pay this coinsurance. You said that you already paid for a brace you received in April, and that one didn't fit properly. You don't believe you should have to pay this coinsurance twice. The Plan denied your request. The Plan says you were charged this coinsurance correctly. The Plan said that you have been granted permission to have this brace remade.
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% coinsurance for prosthetic devices (including braces). You have been asked to pay 20% coinsurance for the ankle/foot brace. The ankle/foot brace falls within the prosthetic devices 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 coinsurance for the ankle/foot brace you received on May 28, 2021.
Your complaint about the first brace being made incorrectly is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) scan of the abdomen.

You asked the Plan to pre-approve MRI services. You say that this care is medically necessary. The Plan denied your request. The Plan says there is no documentation of a referral for the requested services.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that they can require the enrollee to get a referral from the primary care physician before services are provided. 

In this case, there is no evidence that you have received a referral for the requested MRI services. The Plan has confirmed that no referral has been made at this time. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) scan of the abdomen.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for physician services provided to the enrollee on August 25, 2019.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the original claim was processed on August 27, 2019 and required a corrected claim. The corrected claim was received on February 5, 2021 which is past the allowed 12-month timeframe.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a valid claim for these services was not filed until February 5, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on August 25, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has back and neck pain radiating down her arms. The electromyography testing was normal. She underwent neck and shoulder physical therapy but no record of lumbar therapy is provided. There are no red flags on physical exam or failure of physical therapy and weight loss to justify MRI at this time. The services are therefore not reasonable or medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for X-rays provided on April 22, 2021.
You asked the Plan to waive the deductible for X-rays. You say that the enrollee's assisted living facility did X-rays in-house and you were unaware. 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. The enrollee's contract with the Plan says that there is a $500 deductible which applies to out-of-network outpatient diagnostic tests and therapeutic services and supplies. The enrollee received X-rays from an out-of-network provider on April 22, 2021. The record shows that the enrollee had only paid $24.17 toward the $500 deductible prior to receiving the services. Therefore, the enrollee is responsible to pay the allowed amount of $286.18. The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient diagnostic tests and therapeutic services and supplies.
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible which applies to out-of-network outpatient diagnostic tests and therapeutic services and supplies. This cost sharing is a contractual obligation that had not been met at the time X-rays were received on April 22, 2021. Therefore, we decided that the Plan does not have to waive the deductible for X-rays provided on April 22, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve continued services. You say that you now have the coronavirus. The Plan denied your request. The Plan says there are no noted daily skilled nursing or therapy needs.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. Continued SNF services beyond October 17, 2021, were requested. 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 continued services. Our physician reviewer found that from a nursing perspective, you received oral medications, had stable vital signs, and had uncomplicated wound care. There are no identifiable skilled nursing service needs. Regarding rehabilitation services, you were at a standby assist to minimal assist level with functional mobility. You required varying assist with activities of daily living. There are no identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for DME and related supplies provided on June 19, 2021.
You asked the Plan to waive the coinsurance for DME and related supplies. You say that you should have been informed of 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 20% coinsurance for DME and related supplies. You received DME and related supplies on June 19, 2021. The total allowed amount is $539.60 and 20% of that is $107.93.
You have been asked to pay the total coinsurance amount of $107.93 for DME and related supplies. DME and related supplies fall within the DME and related 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 coinsurance for DME and related supplies provided on June 19, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the spine (72141).
You asked the Plan to pre-approve the MRI. You say that the MRI is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the MRI. Our reviewer says that the requested MRI is not medically necessary. Our physician reviewer found the record indicates that the enrollee has an unsteady gait and lower extremity numbness. Physical examination shows ankle clonus. He is scheduled to see neurosurgery. The record indicates that a CT scan of the neck was performed but no results are requested. The records provided do not indicate the medical necessity or reasonableness of the requested service at his time. 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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the spine (72141).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the outpatient office visit (99213) to be provided by an
OON provider.
You asked the Plan to pre-approve the office visit. You say that you would like to have a PCP who will refer
you to your specialist you have been seeing for over 5 years for continuity of care. The Plan denied your
request. The Plan says enrollee's must receive their medical services from an in-network provider with the
exception being urgent or emergent services. Non-emergent services with non-contracted providers require
prior authorization before services being 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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
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. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
the outpatient office visit (99213) to be provided by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the duplex scan of the extracranial arteries; complete bilateral study (93880) and the duplex scan of the aorta, inferior vena cava, iliac vasculature, or bypass grafts; complete study (93978) provided on December 28, 2020.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the services provided.
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 up to a $150 copay for each out-of-network Medicare-covered outpatient diagnostic procedure and test in an outpatient facility.
You have been asked to pay a $150 copayment for the out-of-network Medicare-covered outpatient diagnostic tests provided in an outpatient facility. 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 duplex scan of the extracranial arteries; complete bilateral study (93880) and the duplex scan of the aorta, inferior vena cava, iliac vasculature, or bypass grafts; complete study (93978) provided on December 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve biologic materials to aid in soft and osseous tissue regeneration (D4265) and a bone graft at time of implant placement (D6104).
You asked the Plan to pre-approve the biologic materials and bone graft. The Plan denied your request. The Plan says these services are not covered under the enrollee's benefit plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve biologic materials to aid in soft and osseous tissue regeneration (D4265) and a bone graft at time of implant placement (D6104).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two core buildups, including any pins when required
(D2950 x2).

You asked the Plan to pre-approve the core buildups. You say that buildups and crowns are necessary for teeth
# 15 and 30 to properly restore the teeth. The Plan denied your request. The Plan says this service is not
covered under the enrollee's benefit plan.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve two
core buildups, including any pins when required (D2950 x2).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the enterectomy procedures provided on October 23, 2020, and October 24, 2020, billed with code 44120.
You asked the Plan to pay for the surgical services as billed. You say that this is billed correctly. The Plan denied your request. The Plan says these codes are not supported.
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 44120 is Enterectomy, resection of small intestine; single resection and anastomosis. We asked our coder 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 surgical services as billed.
Our reviewer says that the documentation does not support the use of these codes for the services rendered. Our reviewer found the manual description of code 44120 states, "the physician resects a segment of small intestine and performs an anastomosis between the remaining bowel ends. The physician makes an abdominal incision. Next, the selected segment of small bowel is isolated and divided proximally and distally to the remaining bowel and removed. The remaining bowel ends are reapproximated using staples or sutures. The incision is closed." This description was not documented in the operative notes. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the surgical services as billed have not been met. Therefore, we decided that the Plan does not have to pay for the enterectomy procedures provided on October 23, 2020, and October 24, 2020, billed with code 44120.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve out-of-network physical therapy services.

You asked the Plan to pre-approve out-of-network physical therapy services. You say that you want the facility your surgeon recommended not the in-network facility. You say that your surgery was three months ago and needs physical therapy right away. The Plan denied your request. The Plan says an in-network provider is available.

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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.

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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve out-of-network physical therapy 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. The Plan denied your request. The Plan says the enrollee does not have an illness that requires further hospital 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 physician reviewer found that the enrollee was admitted to the acute hospital with respiratory failure with hypoxia. She required mechanical ventilation. She was successfully removed from the breathing machine and is now breathing on her own with supplemental oxygen. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable.

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.