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

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care from November 6, 2021, forward.
You asked the Plan to pre-approve SNF care. You say that you still need care. The Plan denied your request. The Plan says your medical issues have stabilized.
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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not currently have skilled nursing or therapy needs. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care from November 6, 2021, forward.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a right heart catheterization surgery (93451, C2628, C1894, 93005) rendered on May 11, 2021.
You asked the Plan to waive the coinsurance for a right heart catheterization surgery. You say that you were never aware that every procedure required prior authorization. You also say that you have been seeing this provider since 2018 and everything has always been taken care of with in-network copayments. The Plan denied your request. The Plan says you were charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for out-of-network, outpatient surgery. Authorization rules may apply. You have been asked to pay a $539.62 coinsurance, which is 20% of the allowed amount for a right heart catheterization surgery ($2,698.12 allowed amount x 20% coinsurance = $539.62). Right heart catheterization surgeries 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 coinsurance for a right heart catheterization surgery (93451, C2628, C1894, 93005) rendered on May 11, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for vasectomy surgery.
You asked the Plan to pay for vasectomy. You say that you are having another surgery during which the vasectomy can also be performed. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this sterilization procedure is not necessary for the treatment of an illness or injury so is non-covered.
The Plan must follow Medicare rules. The rules say that items/services for the purposes of preventing conception (contraception) are not considered medically reasonable and necessary. Records show that the requested service is primarily for the purpose of contraception. The documentation does not show that this service is being requested to treat a specific illness/injury. As such, the Medicare rules for coverage of this item/service have not been met. Therefore, we decided that the Plan does not have to pay for vasectomy surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Coolief cooled radiofrequency ablation (RFA).
You asked the Plan to pre-approve Coolief RFA procedure. You say that you are appealing this denial. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the enrollee does not meet the criteria for facet joint injections.
The Plan must follow Medicare rules. Medicare rules say that low-grade thermal energy modalities for facet joint denervation are considered not reasonable and necessary and therefore will be denied. We looked at the file and Medicare rules. Coolief is a cooled radiofrequency ablation modality and is therefore not covered Based on this information, we decided that Medicare rules for coverage of Coolief RFA procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve Coolief cooled radiofrequency ablation (RFA).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary visit provided on June 23, 2021.
You asked the Plan to pay for the domiciliary visit. You say that it is the nursing facility's responsibility to get authorizations. You say the services were medically necessary. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization or referral from a contracted provider. The Plan says the services were not urgent or emergent.
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 visit provided on June 23, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to reimburse you an additional amount for physician's services for a cervical or vaginal cancer screening; pelvic and clinical breast examination provided on April 12, 2021.
You asked the Plan to reimburse you for physician's services. You say that would like an additional $111.02 reimbursed to you, as that is what you were told on your initial phone call in March. The Plan denied your request. The Plan says the Plan advised you that you will be reimbursed the Medicare allowable rates.
The contract with the Plan says you can choose to receive care from out-of-network providers. Our
Plan will cover services from either in-network or out-of-network providers, as long as the services are covered benefits and medically necessary. However, if you use an out-of-network provider, your share of the costs for your covered services may be higher. It is best to ask an out-of-network provider to bill the plan first. But, if you have already paid for the covered services, we will reimburse you for our share of the cost for covered services.
We looked at the file and the Plan's rules. The file shows that the Plan reimbursed you the correct Medicare allowable amount of $48.98. Therefore, we decided that the Plan does not have to reimburse you and additional amount for physician's services for a cervical or vaginal cancer screening; pelvic and clinical breast examination provided on April 12, 2021.
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 transfer to LTACH is crucial for recovery. The Plan denied your request. The Plan says criteria for admission to the LTACH have not been met.
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 that there is no documentation provided necessitating admission to an LTACH. You are receiving appropriate care at the present acute care hospital. You do not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that you require that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for your diagnosis and condition and able to be furnished safely and effectively only on an inpatient basis.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on February 24, 2021, to March 17, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the medical services. You say that these medical services were provided for emergency situations. The Plan denied your request. The Plan says prior authorization was not obtained for these services rendered by an OON provider.
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. There is no evidence that these services were provided during a medical emergency. Therefore, we decided that the Plan does not have to pay for the medical services provided on February 24, 2021, to March 17, 2021, by an out-of-network (OON) provider
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF services.
You asked the Plan to pre-approve SNF services. You say that a SNF admission is medically necessary. The Plan denied your request. The Plan says a SNF admission is not medically necessary. Your needs can be met at a lower level of 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 SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that from a nursing perspective, you received oral medications. You had stable vital signs. You were treated for pain. Regarding rehabilitation services, you received physical therapy (PT) and occupational therapy (OT). By the dates in question, you were at a supervision to contact guard assist level with functional mobility including gait to 175 feet. You required varying assist with activities of daily living. There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. As a practical matter, you do not meet severity of illness or intensity of service criteria for 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services (90837) provided on July 7, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the psychotherapy services. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says prior authorization was not obtained for these services rendered by an OON provider.
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 psychotherapy services (90837) provided on July 7, 2021, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for long term acute care hospital (LTACH) services.
You asked the Plan to pay for the LTACH services. You say that you need LTACH services to get control of your wounds and be able to live a normal life again. The Plan denied your request. The Plan says the criteria for admission to an LTACH are not met. The records do not show that it is likely you will require 25 days or more of continued hospital care while needing to see a doctor every day. The wound and respiratory services you need do not require specialty nursing care. Your continued care can be provided in an alternate setting.
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 pay for 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 there is no documentation provided necessitating admission to a LTACH. You are receiving appropriate care at the present acute care hospital. You do not require services at the LTACH that are not available at the acute care hospital where you are currently receiving care. There are no services available at the LTACH that you require that are not available at the health care setting being offered by the health plan.
The requested LTACH services are not medically necessary, reasonable, and appropriate for your diagnosis and condition and able to be furnished safely and effectively only on an inpatient basis. 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 pay for long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transport chair (E1038) to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve transport chair. You say that you attempted to reach out to several in-network suppliers, but none were able to accommodate your needs. The Plan denied your request. The Plan says the denial of authorization for this item is correct, because this provider is out-of-network with the Plan and this item can be supplied by an in-network provider.
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 a transport chair (E1038) to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eyelash procedure provided on August 2, 2021.
You asked the Plan to waive the copayment for the eyelash procedure. You say that, before the appointment, you were told there would be no copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for each specialist office visit. You have been asked to pay $29.26, which is less than the $40 copayment for the eyelash procedure. The eyelash procedure 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 the eyelash procedure provided on August 2, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance service, basic life support, emergency transport (A0429) with a QL modifier, provided on November 21, 2020.
You asked the Plan to pay for ambulance service, basic life support, emergency transport (A0429) with a QL modifier. The Plan denied your request. The Plan says the claim was not billed according to CMS guidelines.
The Plan must follow Medicare rules. Medicare rules say that providers report the A0428 (BLS) HCPCS code. Providers report modifier QL (Patient pronounced dead after ambulance called) instead of the origin and destination modifier.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ambulance services (A0429-QL) have not been met. Specifically, code A0429 is not the appropriate code for billing Medicare when the enrollee is pronounced dead after the ambulance is called. Medicare requires the reporting of A0428 for services provided under these circumstances. Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, emergency transport (A0429) with a QL modifier, provided on November 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the occlusal guard (D9944) provided on July 6, 2021.
You asked the Plan to pay for the dental item. You say that your dentist advised the appliance would help relieve your pain and keep your temporomandibular joint (TMJ) from getting worse. You say that you wear the guard day and night except for when you are eating. You also say that you were not told prior to the service being rendered that it would not be covered or how much it would cost. The Plan denied your request. The Plan says the occlusal guard is not listed as a covered dental item. The Plan also says that you signed a financial agreement prior to receiving the service acknowledging financial responsibility for all charges whether or not paid by your insurance.
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 occlusal guard is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the occlusal guard (D9944) provided on July 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services represented by procedure codes 99123 and 99203 you received from May 12, 2021, to May 21, 2021.
You asked the Plan to pay for the chiropractic services. You say that all three of these visits were for manipulation for emergency acute therapeutic care, not maintenance. You said that you should be reimbursed for these services. The Plan denied your request. The Plan says it has denied payment for the office visits correctly. The Plan says that it has made additional payment for the manual manipulation service that was provided on May 14, 2021.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Specifically, the records show that on May 12, 2021, May 14, 2021, and May 21, 2021, this provider billed for an office visit (codes 99213 and 99203). Only manual manipulation of the spine (code 98942) is a covered benefit. The Plan has paid for the manual manipulation code billed for date of service May 14, 2021, minus your applicable copayment. These office visit services are not covered under your contract or by Medicare rules. Therefore, we decided that the Plan does not have to pay for the chiropractic services represented by procedure codes 99123 and 99203 you received from May 12, 2021, to May 21, 2021.