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

We decided that the Plan does not have to waive the copayment for a specialist visit provided on October 14,
2021.
You asked the Plan to waive the copayment for a specialist visit. You say that you feel that the visit does not
warrant a copayment. 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 $40
copayment for each specialist visit.
You have been asked to pay a $40 copayment for a specialist visit. A specialist visit falls 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 copayment for a specialist visit provided on October 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit (99202) provided by a
specialist on December 2, 2021.
You asked the Plan to waive the copayment for the office visit. You say that you feel you should not be
responsible for this payment because the provider did not prescribe you medication during this visit, and you
feel the care was inadequate to fix your problem. The Plan denied your request. The Plan says this claim was
processed correctly, and your copayment was assessed in accordance with your contract. The Plan also says
that your other complaints are being addressed as a separate grievance.
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 $35
copayment for each in-person specialist visit.
You have been asked to pay a $35 copayment for the office visit provided by a medical specialist. Medical
records show that an office visit occurred on the date in question. 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 (99202) provided by a specialist on December 2, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the infrared therapy (97026) provided on September 17, 2021.

You asked the Plan to pay for the infrared therapy. You say that the service was medically necessary. The Plan denied your request. The Plan says infrared therapy is not covered by Medicare or the Plan.

The Plan must follow Medicare rules. Medicare rules say that infrared therapy devices and any related accessories is not reasonable and necessary. 

We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the infrared therapy have not been met. Specifically, the file shows that infrared therapy devices and any related accessories is not reasonable and necessary. Therefore, we decided that the Plan does not have to pay for the infrared therapy (97026) provided on September 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services received on September 11, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says this code should not be unbundled.
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, we have confirmed that code 70450
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we
decided that the Plan does not have to pay for imaging services received on September 11, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care.

You asked the Plan to pre-approve the continuation of SNF care. You say that the requested continuation of SNF care is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for continued SNF care.

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 pre-approve the continuation of SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found at the time of admission, the member required skilled rehab services to improve function due to weakness and deconditioning. There were no skilled nursing needs. As of February 16, 2022, the member did not require any skilled nursing or rehab services on a daily basis. 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. The member did not require skilled therapy to establish a safe and effective maintenance program. As a practical matter, the member did not require any skilled services on an inpatient basis, at a SNF level of care as of February 16, 2022. The member did not have any parental medications, complex wound care or nutrition given via a feeding tube. The member received skilled care and improved; however, her functional improvement had plateaued by February 16, 2022, and she did not require any further inpatient skilled rehab services. The member's function was at or near her prior level of function and she could be discharged to a lower level of care for further services. As of February 16, 2022, the member required custodial 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 the continuation of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the ConfirmMDx testing rendered on May 11, 2021.
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 testing is not covered.
The Plan must follow Medicare rules. The rules say that ConfirmMDx testing is covered for males with
previous negative prostate biopsy who are being considered for repeat biopsy.
We looked at the file and Medicare rules. The file does not contain documentation of a previous prostate
biopsy. 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 pay for the ConfirmMDx testing rendered on May
11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the shipping charge incurred on June 1, 2021.
You asked the Plan to pay for the shipping charge. You say that you are requesting reimbursement. The Plan
denied your request. The Plan says that this is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. Medicare rules say that separate delivery and services charges for
oxygen or durable medical equipment are only covered in rare and unusual circumstances when the delivery is
not typical of the particular supplier's operation.
Review of the file shows that the shipping charges are not a covered benefit. Therefore, we decided that the
Plan does not have to pay for the shipping charge incurred on June 1, 2021.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for the radiologic examination, of the ribs, unilateral; including
posteroanterior chest, minimum of 3 views (71101), and the radiologic examination, of the spine, lumbosacral;
2 or 3 views (72100) provided on September 7, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says that the services were rendered by an out of
network provider, without prior authorization.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. Specifically, the radiology services provided in this case were the result of an
urgent care visit. Urgent care is covered out-of-area and out-of-network in certain circumstances. The Plan has
failed to address this coverage aspect and has not substantiated their denial issued. Therefore, we decided that
the Plan has to pay for the radiologic examination, of the ribs, unilateral; including posteroanterior chest,
minimum of 3 views (71101), and the radiologic examination, of the spine, lumbosacral; 2 or 3 views (72100)
provided on September 7, 2021.
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: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an Intracept procedure.  You asked the Plan to pre-approve an Intracept procedure. You say that the requested service is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the requested service is experimental/investigational.  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 an Intracept procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the requested procedure is considered experimental/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 an Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve an Intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Shingles vaccine (90750) provided on April 2, 2021,
and October 1, 2021.
You asked the Plan to pre-approve the Shingles vaccine. You say that you would like reconsideration because
this vaccine should be covered. The Plan denied your request. The Plan says this vaccine is not covered under
Medicare Part B.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Shingles
vaccine. The Plan follows the same rules.
Records do not show that you have been injured or directly exposed to any illness related to the Shingles
vaccine. Therefore, we decided that the Plan does not have to pre-approve the Shingles vaccine (90750)
provided on April 2, 2021, and October 1, 2021.
Benefits for the Shingles vaccine 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network chiropractic services provided from August 28, 2021, to September 10, 2021.

You asked the Plan to pay for out of network chiropractic services. You say that the provider did not tell you they were out of network. The Plan denied your request. The Plan says you did not have prior authorization for out of network chiropractic care.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that if you get out of network care from a chiropractor, you will pay the entire cost of the service. The provider used was not a network provider with the Plan. The Plan did not pre-approve this service. Enrollees are responsible for insuring they are being seen by contract providers when necessary. 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 out of network chiropractic services provided from August 28, 2021, to September 10, 2021.
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 you would like reconsideration because the requested IRF care is medically necessary. The Plan denied your request. The Plan says you do not meet Medicare criteria for coverage of the IRF 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 in the Medicare rules section.  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 with your comorbid conditions being stable, you do not need Physical Medicine and Rehabilitaion physician supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. No acute or complex rehab nursing needs are noted in the record. With an uncomplicated pelvic fracture and with your current functional status, you need Physical Therapy and Occupational Therapy, but do not need intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. You can be safely rehabilitated in a Skilled Nursing Facility.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for cystourethroscopies and an injection
procedure for imaging of the kidney provided from July 13, 2021, to August 3, 2021.
You asked the Plan to waive the copayments for cystourethroscopies and an injection procedure for imaging of
the kidney. You say that these were follow-up procedures and 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 $350
copayment for outpatient surgery, including services provided at hospital outpatient facilities.
You received a cystourethroscopy at an outpatient hospital facility on July 13, 2021. A cystourethroscopy is
considered an outpatient surgical procedure. Therefore, you are responsible to pay the $350 copayment.
You received a cystourethroscopy at an outpatient hospital facility on July 27, 2021. A cystourethroscopy is
considered an outpatient surgical procedure. Therefore, you are responsible to pay the $350 copayment.
You received an injection procedure for imaging of the kidney at an outpatient hospital facility on August 3,
2021. Therefore, you are responsible to pay the $350 copayment.
The total amount you owe is: $1,050.
You have been asked to pay the total copayment amount of $1,050 for cystourethroscopies and an injection
procedure for imaging of the kidney. Cystourethroscopies and an injection procedure for imaging of the kidney
fall 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 copayments for cystourethroscopies and
an injection procedure for imaging of the kidney provided from July 13, 2021, to August 3, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on February 23, 2021.

You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says this is not a covered screening service.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. 

The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab services provided on February 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for arthrocentesis provided on June 24, 2021.

You asked the Plan to waive the copayment for arthrocentesis. You say that you disagree with how the procedure processed as a surgical procedure. 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 $295 copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers. 

The record shows that you received arthrocentesis at an outpatient hospital facility on June 24, 2021. Arthrocentesis is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $295 copayment.

You have been asked to pay a $295 copayment for arthrocentesis. Arthrocentesis falls within the outpatient surgery and other medical 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 arthrocentesis provided on June 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the virtual (telehealth) outpatient office visit provided on October 4, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the telehealth visit. You say that particular services were paid for in the past, and you do not understand why they were not paid for this time. The Plan denied your request. The Plan says telehealth services provided by an out of network provider is not covered by the Plan.

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 virtual (telehealth) outpatient office visit provided on October 4, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a reverse total shoulder arthroplasty (23472).

You asked the Plan to pre-approve a reverse total shoulder arthroplasty. You say that the requested service is a medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for coverage for the requested service have 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 reverse total shoulder arthroplasty. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that detailed documentation is not evident regarding trial and failure of recent, reasonable, and comprehensive less invasive conservative care measures. The documentation provided for review does not corroborate a trial and failure of medications or physical therapy. Additionally, there are no imaging studies of the right shoulder to corroborate pathology that would be amenable to the requested procedure. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception.

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 reverse total shoulder arthroplasty have not been met. Therefore, we decided that the Plan does not have to pre-approve a reverse total shoulder arthroplasty (23472).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a MitraClip procedure. You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the service is not covered.

The Plan must follow Medicare rules. Medicare rules say that transcatheter repair for mitral valve regurgitation is only covered under certain medical indications.

We looked at the file, and Medicare rules. In this case, the records do not indicate the enrollee is part of an audited registry. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve a MitraClip procedure.