Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit with an ophthalmologist (99212) provided on September 22, 2021.
You asked the Plan to waive the copayment for the office visit. You say that you were told by office staff that you would not have a copayment for these services. The Plan denied your request. The Plan says they investigated your claims and found that the provider denied that you were told there would be no copayment by the office staff. The provider in this case is an independent provider and is neither owned nor controlled by the Plan. The Plan also cannot confirm nor deny the account of events as stated in your appeal. As it is, the claim was processed correctly, and your copayment was assessed in accordance with your contract.
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 $30 copayment for office visit with a specialist.
You have been asked to pay a $30 copayment for the office visit with an ophthalmologist. 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 with an ophthalmologist (99212) provided on
September 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit (99336) provided on June
9, 2021, by an OON provider.
You asked the Plan to pay for domiciliary or rest home visit. You say that your physician provided medically
necessary services to the enrollee in good faith. 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 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 domiciliary or rest home visit (99336)
provided on June 9, 2021, by an OON provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation mileage.
You asked the Plan to pre-approve additional routine transportation mileage. You say that the additional transportation mileage is necessary. The Plan denied your request. The Plan says the benefit has been exhausted. Therefore, coverage criteria have not been met.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers 100 one-way transportation trips when each one-way trip does not exceed 60 miles. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation mileage.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for magnetic resonance imaging (MRI) of the lumbar spine provided on August 2, 2021.
You asked the Plan to waive the coinsurance for the MRI. You say that you cannot afford the copayment. The Plan denied your request. The Plan says the correct coinsurance was applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for each diagnostic radiology service. You have been asked to pay $90, which is 20% of the allowed amount for the MRI ($450 allowed amount x 20% coinsurance = $90). The MRI falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for magnetic resonance imaging (MRI) of the lumbar spine provided on August 2, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar spine surgery with placement of Coflex device.
You asked the Plan to pre-approve lumbar spine surgery with placement of Coflex device. You say that the lumbar spine surgery with placement of Coflex device is medically necessary. The Plan denied your request. The Plan says the lumbar spine surgery with placement of Coflex device is not medically necessary.
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 lumbar spine surgery with placement of Coflex device. Our reviewer says that the lumbar spine surgery with placement of Coflex device is not medically necessary. Our physician reviewer found the enrollee is with spondylosis with radiculopathy in the lumbar region. The enrollee has chronic low back pain which radiates into the right buttocks and down the right lower extremity. A Magnetic resonance imaging (MRI) in April 2021 demonstrated severe spinal canal narrowing at the L4-5 level. The enrollee also has right hip and knee pathologies. Coflex is an implanted interlaminar stabilization device. There is insufficient evidence that the Coflex device is medically reasonable and necessary in this 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 lumbar spine surgery with placement of Coflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar spine surgery with placement of Coflex device.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve continuation of pertuzumab 1MG injection (CPT code J9306) and
trastuzumab, excludes biosimilar, 10MG injection (CPT code J9355) from February 26, 2022, through March
31, 2022, to be provided by an out-of-network provider.
You asked the Plan to pre-approve the injections. You say that you moved out of state. You state you are only
on vacation and need your injections. You state this affects your Parkinson symptoms, you must receive
injections every three (3) weeks and now you are over a week behind. You state this is a preventative
medication to keep cancer from returning and your health is at risk. The Plan denied your request. The Plan
says that you need to have a medically reasonable explanation from your doctor why the Pertuzumab and
Trastuzumab injections are to be done with an out-of-network provider/facility to qualify for coverage;
therefore, you do not meet the criteria.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item
or service, then that item or service will be covered when it is medically necessary.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the injections. Our reviewer found that
it is documented that you are on vacation. Consequently, the documentation supports that you could have
foreseen requiring the services prior to leaving your service area. It is documented in the case file that you plan
to move back to Boston in March. It would not be medically reasonable to delay your treatment until March 31,
2022, or when you disenrolled from the plan, or up to six (6) months. The medical records support that the
requested care is 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 the injections have been met. Therefore,
we decided that the Plan has to pre-approve continuation of pertuzumab 1MG injection (CPT code J9306) and
trastuzumab, excludes biosimilar, 10MG injection (CPT code J9355) from February 26, 2022, through March
31, 2022, to be provided by an out-of-network provider.
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: ER
Decision: Unfavorable

 We decided that the Plan does not have to lower the copayment for the urgent care services provided on August 24, 2021.  You asked the Plan to lower the copayment for the urgent care services. You say that the copayment should have been lower. The Plan denied your request. The Plan says the applied copayment was 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 a $50 copayment for urgently needed services and the cost sharing is the same for out-of-network and in-network providers.     You have been asked to pay a $50 copayment for the urgent care services. Urgent care services falls within the Urgently needed 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 lower the copayment for the urgent care services provided on August 24, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eight (8) additional physical therapy visits.
You asked the Plan to pre-approve the visits. You say that the services are necessary. The Plan denied your request. The Plan says the services are not necessary.
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 visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the additional requested therapy is not generally accepted as specific and effective therapy for the patient's condition beyond what was approved by the health plan. You have had prior extensive therapy for this condition and the records do not demonstrate that the ongoing unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. You have been instructed in and are compliant in a home exercise program. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration. 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 visits have not been met. Therefore, we decided that the Plan does not have to pre-approve eight (8) additional physical therapy visits.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says that the enrollee does not meet criteria for IRF 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 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 enrollee meets criteria for IRF admission. Our physician reviewer found based on the documentation provided, the enrollee does not have documented skilled nursing needs. The enrollee does have documented skilled therapy needs. The enrollee is functioning below her reported baseline. The documentation does not yet establish that the enrollee has reached a new plateau in function. A trial of daily skilled services is reasonable to establish a maintenance program and/or to prevent deterioration of the enrollee's condition. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have been met. Therefore, we decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
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 long term acute care hospital (LTACH) services.  You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.  The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee appears to be more stable and should only require short-term additional acute care services that can be safely received at the current hospital for now until it is clearer if the enrollee is a good candidate for weaning. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer may be considered when treatment has completed.   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.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for tenodesis of long tendon of biceps (CPT code 23430 XS-51-
LT) and revision of total shoulder arthroplasty, including allograft when performed; humeral or glenoid
component (CPT code 23473-LT) provided to the enrollee on July 6, 2021.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your
request. The Plan says the services are not supported by the records.
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 physician reviewer found
documentation submitted was reviewed and does not meet criteria. Operative report does not describe removal
of an old shoulder replacement and a new one inserted, which would be reported as a revision of total shoulder
arthroplasty was performed. Therefore, CPT 23473 is not supported. For CPT 23430, since CPT 23473 cannot
be verified, this procedure cannot be verified, since in certain circumstances CPT 23430 would be reported
separately. Therefore, by the documentation submitted, confirmation of CPT 23430 as a separate procedure
cannot be confirmed.
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 tenodesis of long tendon of biceps (CPT code 23430 XS-51-LT) and revision of total shoulder
arthroplasty, including allograft when performed; humeral or glenoid component (CPT code 23473-LT)
provided to the enrollee on July 6, 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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that you can safely receive the services you need in other settings.
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. The complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
The patient was admitted for sepsis, urinary tract infection, and atrial fibrillation. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the patient has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care. 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 for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission.
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 admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF. The documentation does not reveal evidence of complex wound care, new enteral feedings, or other skilled nursing SNF need. The enrollee's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee does not require skilled nursing or skilled therapy services (or a combination of these services) on a daily basis in a SNF. As a practical matter this enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility 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 admission to a SNF have not been met. Therefore, we decided that the Plan does not have to pre-approve the admission to a skilled nursing facility (SNF).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital care provided from July 1, 2021, to
July 19, 2021.
You asked the Plan to pay for the inpatient care. You say that the enrollee was not stable for discharge during
this period and required ongoing care at the inpatient level. The Plan denied your request. The Plan says the
enrollee's benefit of 90 days and the reserve benefit of 60 days have both been exhausted prior to the dates of
service in this case.
The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if
regular Medicare would pay for it in this case. Medicare covers up to 90 inpatient hospital or inpatient critical
access hospital (CAH) days in each benefit period. Each beneficiary also has a non-renewable lifetime reserve
of 60 days of inpatient hospital or inpatient CAH services that can be drawn upon whenever the beneficiary is
hospitalized for more than 90 days in a benefit period.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the inpatient care have not been met. Specifically, the file shows that the inpatient hospital care
benefit has been exhausted. The record shows that the enrollee had used 43 of the 90 total allowed days from
January 7, 2021, to January 15, 2021, and from January 30, 2021, to March 6, 2021. The record also shows that
the Plan paid for inpatient care provided from March 6, 2021, to June 21, 2021 (107 days), thus exhausting the
number of allowed days per inpatient benefit period as well as the 60 lifetime reserve days. Therefore, we
decided that the Plan does not have to pay for the inpatient hospital care provided from July 1, 2021, to July 19,
2021.