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

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from May 7, 2021 to May 31, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the SNF care. You say that no hospital admission is necessary as you are not a hospital. You say that room and board is covered since the enrollee was not receiving skilled services. You also say that the services were rendered to the enrollee in good faith. The Plan denied your request. The Plan says you need to work with your primary care physician or network specialist before requesting out of network care.
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 provider in this case is not a network provider with the Plan. 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 skilled nursing facility (SNF) care provided from May 7, 2021 to May 31, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on April 29, 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 services are not covered.

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 test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on April 29, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on August 5, 2021.
You asked the Plan to waive the copayment for ambulance services. You say that you thought that the ambulance services would be included in the hospital 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 $250 copayment for ambulance services. You have been asked to pay a $250 copayment for ambulance services. Ambulance services fall within the ambulance services benefit category.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance services provided on August 5, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the presumptive drug testing rendered on June 28, 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 frequency limit is exceeded.

The Plan must follow Medicare rules. The rules state that Medicare will only pay for one presumptive UDT test per patient per date of service regardless of the number of billing providers. 

We looked at the file and Medicare rules. The file shows that the presumptive drug testing was billed more than once for this enrollee. 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 presumptive drug testing rendered on June 28, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the abdominal ultrasound provided on August 18, 2021.

You asked the Plan to pay for the services provided. You say that the enrollee had multiple exams on this date of service. The Plan denied your request. The Plan says an appropriate modifier was not billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. 

The file shows that CPT code 76705 was billed with code 93976. We find that CPT code 76705 may be eligible for payment when billed with this code pair. However, the claim information does not show that the code at issue was billed with a modifier suitable for payment. 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 pay for the abdominal ultrasound provided on August 18, 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 the services are 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. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the enrollee does not require the intensity of services provided at an IRF.
Specifically, the enrollee is not shown to currently be able to tolerate fifteen hours per week of rehabilitative
services with regular physician evaluation. The enrollee's care needs can be met at a lower level of 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.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda (J9271).
You asked the Plan to pre-approve Keytruda (J9271). You say that the item is medically necessary. The Plan denied your request. The Plan says the item is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Keytruda (J9271). Our reviewer says that the item is not medically necessary. Our physician reviewer found the item is not FDA-approved for the enrollee's diagnosis and the use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda (J9271) have not been met. Specifically, the item is not FDA-approved for the member's diagnosis and is considered not medically necessary. Therefore, we decided that the Plan does not have to pre-approve Keytruda (J9271).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapeutic crisis services (90839) provided on July 18, 2021.
You asked the Plan to pay for psychotherapeutic crisis services. You say that the services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met because the provider of the services at issue is not enrolled in the Medicare program.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program.
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for psychotherapeutic crisis services (90839) provided on July 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the visit you had with a nurse practitioner specialist at an immediate care center on March 11, 2021.

You asked the Plan to waive the copayment for the specialty visit. You say that you were instructed to have this visit due to an allergic reaction you had to the Pfizer vaccine you received on March 9, 2021. You believe you should not have to pay anything for vaccine-related expenses. The Plan denied your request. The Plan says you were charged this copayment correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25 copayment for visits with a specialist. 

You have been asked to pay a $25 copayment for the specialty visit. There is no provision in your contract for a
waiver of this copayment even if the visit was needed as a result of an allergic reaction to the vaccine. 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 visit you had with a nurse practitioner specialist at an immediate care center on March 11, 2021.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve Computed Tomography (CT) scan of the abdomen (74178).
You asked the Plan to pre-approve the CT scan. You say that the CT scan is medically necessary. The Plan denied your request. The Plan says that coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 CT scan. Our reviewer says that the requested CT scan is medically necessary. Our physician reviewer found the enrollee has had a thorough endoscopic workup and presents with lower abdominal pain and tenderness as well as a history of infectious colitis. CT is the next procedure of choice and the tandem without and with contrast is necessary in order to search for abnormal enhancement of bowel wall or abnormal fluid collection if a suspected abscess were to be discovered. 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 CT scan have been met. Therefore, we decided that the Plan has to pre-approve Computed Tomography (CT) scan of the abdomen (74178).
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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional twenty (20) physical therapy (PT) visits
You asked the Plan to pre-approve the additional twenty (20) PT visits. The Plan denied your request. The Plan says twenty (20) additional physical therapy visits are not medically 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 additional twenty (20) PT visits. Our reviewer says that skilled services are not medically necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that based on the available records the enrollee appears to have improved with therapy to the point of being able to manage her activities of daily living. Further formal therapy at this point does not appear to be likely to achieve any significant improvement in the enrollee's symptoms or functional status. Further utilization of her home exercise program appears appropriate at this point. Based on the medical records provided there is no documentation that the 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 under the supervision of a therapist. There is no documentation that the specialized skill, knowledge and judgment of a qualified therapist is required to establish, design and/or deliver a program to maintain the enrollee's 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 additional twenty (20) PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve an additional twenty (20) PT visits.
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 IRF care is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says rules for IRF care have not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of 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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99204) and the myringotomy including aspiration and/or eustachian tube inflation (69420) rendered by the out-of-network (OON) provider on July 30, 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 the services were rendered by an out of network 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the office visit (99204) and the myringotomy including aspiration and/or eustachian tube inflation (69420) rendered by the out-of-network (OON) provider on July 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided in excess of $1,300 from February 3, 2021, to May 24, 2021.
You asked the Plan to pay for the dental services. You say that you were given incorrect information by a plan representative and were told that your benefits renewed on April 1st. The Plan denied your request. The Plan says the services in question exceeded your annual allowance for supplemental dental care. The Plan has also reviewed your call logs and addressed your grievance in a separate case.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. This benefit covers up to $1,300 every year for supplemental dental care. You are responsible for any amount above the dental coverage limit.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services were provided in excess of the Plan's annual maximum allowance for dental care. Documentation shows that the Plan has already paid the full $1,300 allowance for dental care in 2021. Therefore, we decided that the Plan does not have to pay for the dental services provided in excess of $1,300 from February 3, 2021, to May 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a carpal tunnel injection provided on September 27, 2021.
You asked the Plan to waive the copayment for a carpal tunnel injection. You say that you disagree with the high charges and feel that the procedure should not be considered 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 $275 copayment for outpatient surgery, including services provided at hospital outpatient facilities. The record shows that you received a carpal tunnel injection at an outpatient hospital facility on September 27, 2021. Therefore, you are responsible to pay the allowed amount of $234.56, which is less than the $275 copayment.
You have been asked to pay $234.56 for a carpal tunnel injection. A carpal tunnel injection falls 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 copayment for a carpal tunnel injection provided on September 27, 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 the enrollee meets the criteria for an IRF admission. The Plan denied your request. The Plan says IRF care is not medically reasonable and necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to be able to tolerate fifteen hours per week of rehabilitative services with regular physician evaluation. The enrollee's care needs can be met at a lower level of care (ex. SNF/SAR). 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: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment for hearing services provided on August 5, 2021.

You asked the Plan to waive the copayment for hearing services. You say that you disagree with the additional
charge for hearing services. The Plan denied your request. The Plan says that 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. Your
contract with the Plan says that enrollees must pay a $0 copayment for hearing services.

The Plan says you must pay a $25 copayment for hearing services. Based on the Plan contract, however, you
cannot be asked to pay more than a $0 copayment for hearing services. Therefore, we decided that the Plan has
to waive the copayment for hearing services provided on August 5, 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: 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 the enrollee is very unstable. You say that IRF care would help the enrollee move along faster in his rehabilitation. The Plan denied your request. The Plan says IRF care is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of 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.