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

We decided that the Plan does not have to pay for Skilled Nursing Facility services provided on May 8, 2021,
by an out-of-network (OON) provider.
You asked the Plan to pay for the Skilled Nursing Facility services. You say that the services should be covered. The Plan denied your request. The Plan says the services denied correctly as you did not obtain prior authorization and the services were not urgent.
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 Skilled Nursing Facility services provided on May 8, 2021, 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 a nephrology specialist visit provided on September 29, 2021.
You asked the Plan to waive the copayment for a specialist visit. You say that you were admitted to the hospital during this time. 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 visit, including care provided in a hospital outpatient department.
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 September 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network medical services provided to the enrollee on September 17, 2021.

You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for 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 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 out of network medical services provided to the enrollee on September 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge day management services (99239)
provided on January 28, 2021.
You asked the Plan to pay for the hospital discharge day management services. You say that you would like
reconsideration because it was medically necessary for the member to be seen by physicians of different
specialties. The Plan denied your request. The Plan says only one hospital discharge day management service is
payable per patient per hospital stay.
The Plan must follow Medicare rules. Medicare rules say that only one hospital discharge day management
service is payable per patient per hospital stay.
We find that CPT code 99239 is not supported in the medical record. Specifically, the documentation submitted
shows that another hospital discharge day management service was billed and paid for the same hospital stay.
Based on this information, we decided that Medicare rules for coverage of the hospital discharge day
management services have not been met. Therefore, we decided that the Plan does not have to pay for the
hospital discharge day management services (99239) provided on January 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910) and scaling and root planing (D4342) provided on April 27, 2021.
You asked the Plan to pay for the dental services. You say that the services should be covered. The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The Plan also says that payment cannot be made to providers that have opted out of Medicare.
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, dental services performed by a provider that has opted out of Medicare are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the periodontal maintenance (D4910) and scaling and root planing (D4342) provided on April 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown (D2740) for tooth # 5 provided on October 7, 2021.

You asked the Plan to pay for the dental service. You say that the service you received was billed incorrectly. You say that you received a crown repair and not a new crown. The Plan denied your request. The Plan says crowns are covered once per tooth every 5 years. The Plan also says that the frequency limits has been exceeded.

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 and crowns are listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a crown for tooth # 5 that you received on September 15, 2020. Therefore, we decided that the Plan does not have to pay for the crown (D2740) for tooth # 5 provided on October 7, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the records provided support the need for LTACH care. The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says that the enrollee can safely receive the care needed in the hospital where he is now.
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 there is no documentation provided indicating medical necessity for admission to a LTACH.
The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care.
There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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 LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone replacement graft (D7953) and collection and application of autologous blood concentrate (D7921) provided on September 15, 2021.

You asked the Plan to pay for the dental services. You say that these services were necessary to save your tooth from decay. The Plan denied your request. The Plan says these services are not covered by your dental benefit.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the bone replacement graft (D7953) and collection and application of autologous blood concentrate (D7921) provided on September 15, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet criteria.
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 have any parental medication; complex wound care or nutrition given via a feeding tube. You are medically stable without any acute exacerbations of chronic medical problems. Your physical function is at or near your baseline and you can receive services 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional payment for the frames (V2020), progressive lenses (V2781), and anti-reflective coating (V2750) provided July 15, 2021.

You asked the Plan to provide additional payment for the frames and progressive lenses with anti-reflective coating. You say that you feel you are due additional reimbursement. The Plan denied your request. The Plan says your full vision benefit was applied to your frames and lenses.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers routine eyewear up to $250 every year. 

We looked at the file and the Plan's rules. In this case the Plan provided documentation showing that your full $250 routine eyewear benefit was applied to this claim. Therefore, we decided that the Plan does not have to provide additional payment for the frames (V2020), progressive lenses (V2781), and anti-reflective coating (V2750) provided July 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network medical services provided to the enrollee from September 27, 2021, to November 1, 2021.

You asked the Plan to pay for these services. You say that these claims should be paid by the Plan. The Plan denied your request. The Plan says the enrollee did not have prior authorization for 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 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 out of network medical services provided to the enrollee from September 27, 2021, to November 1, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital services you received
from September 8, 2021, to September 11, 2021.
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you almost died
because you contracted Coronavirus Disease 2019 (COVID-19). You said that the Plan should cover this
whole bill. 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 $225
copayment per day for days 1-7 for inpatient hospital care.
Records show that you were in the hospital for 3 days. You were charged a $225 copayment per day, for a
total of $675. This copayment applies regardless of the reason for these services.
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 inpatient hospital services you received from September
8, 2021, to September 11, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.

You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says the enrollee has no daily skilled therapy or nursing needs.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.

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 physician reviewer found that the most recent therapy documentation indicates the enrollee is able to ambulate and accomplish mobility without hands on assistance. He is medically stable and does not have any complex daily wound care, parental medications or required care for a new or malfunctioning feeding tube. He does not require skilled nursing and/or skilled therapy services on a daily basis. Therefore, an admission to a SNF for inpatient skilled rehab services is not 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a home ventilator.

You asked the Plan to pre-approve a home ventilator. You say that bilevel treatment has been considered for
the enrollee but they do not offer the best mode of ventilation for his disease process. You say that noninvasive
ventilator offers battery life of 8 hours which can be used in the event of power outage as interruption
of ventilation could lead to serious medical consequences. The Plan denied your request. The Plan says that
there are no documents supporting that a bilevel positive airway pressure (BiPAP) has been tried and failed.

The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory
failure due to COPD.

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 home ventilator. Our reviewer says
that the criteria for coverage have been met. Our physician reviewer found a home ventilator is reasonable and
medically necessary for this enrollee. The enrollee has amyotrophic lateral sclerosis, a progressive generalized
neuromuscular disease. His most recent vital capacity on spirometry testing was 49% of predicted. This meets
Medicare criteria for a home ventilator with a diagnosis of neuromuscular disease (VC less than 50%).
Because this disease is progressive, he will need certain functions found with a ventilator but not with BiPAP,
such as sip-and-puff ventilation for used while awake, and battery backup.

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 home ventilator have been met. Therefore, we decided that the Plan has to
pre-approve a home ventilator.

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 pay for an intrauterine device placement procedure (58300) for a Mirena intrauterine contraceptive system (J7298) and a urine pregnancy test (81025) provided on September 10, 2021.

You asked the Plan to pay for an intrauterine device placement procedure for a Mirena intrauterine contraceptive system and a urine pregnancy test. You say that the requested items are a medical necessity for you. The Plan denied your request. The Plan says rules for payment have not been met.

The Plan must follow Medicare rules. The rules say that Medicare does not allow payment for contraceptive devices or medication. 

The Current Procedural Terminology (CPT) codes for the items at issue have status indicators of "N" (58300 and J7298) or "X" (81025) on the Physician Fee Schedule

This means that the codes at issue are invalid for Medicare billing purposes. Based on this information, we decided that Medicare rules for coverage of an intrauterine device placement procedure for a Mirena intrauterine contraceptive system and a urine pregnancy test have not been met. Therefore, we decided that the Plan does not have to pay for an intrauterine device placement procedure (58300) for a Mirena intrauterine contraceptive system (J7298) and a urine pregnancy test (81025) provided on September 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve a CGM and supplies. You say that this is medically necessary. The Plan denied your request. The Plan says that medically necessary care is available in network.

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 continuous glucose monitor (CGM) and supplies to be provided by an out-of-network (OON) provider.
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 need to go to rehabilitation. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.

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 the complexity of your nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While you may need physical and/or occupational therapy, there is no documented need for an intensive rehabilitation therapy program. There is not a reasonable expectation that you will be able to fully participate in - and benefit from - the intensive rehabilitation therapy program provided in an IRF. 

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 out of network medical services provided to the enrollee on October 25, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for 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 must 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 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 out of network medical services provided to the enrollee on October 25, 2021.