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

We decided that the Plandoes not haveto pay fordrug testing services provided to the enrollee on July 8, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthe records do not support the service billed.The Plan must follow Medicare rules. Medicare rules say that a physician order must be present for labs to be covered.The documentation submitted did not include a physician order/lab requisition or medical records stating exactly tests were to be performed. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plandoes not haveto pay fordrug testing services provided to the enrollee on July 8, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you foran annual fee for a gym membership from September 5, 2019 to October 2, 2019.You asked the Plan to reimburse you forthe annual fee for a gym membership. You say that you would like to continue attending the "the gym" or be reimbursed the $25 membership fee. You say that you should have been notified about the denial before attending "the gym".The Plan denied your request. The Plan says you can only be enrolled with one gym at a time and must call and notify of the changes. Additionally, due to moving out of the Plan's coverage area, your plan benefits termed September 30, 2019 thus denying future participation inthe fitness program.The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules applyin this case.The Plan's rules for coverage of gym benefitshave not been met. Therefore, we decided that the Plan does not have to reimburse you foran annual fee for a gym membership from September 5, 2019 to October 2, 2019.
Appeal type: Other
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadditional mileage.You asked the Planto pre-approvethe additional mileage. You say that this is medically necessary.The Plandenied your request. The Plansaysan additional 85 miles is not a covered benefit.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 routine transportation when the trip is upto 50 miles one-way.We looked at your request, the records in the case file, and the rules. The requested trip is a total of 135 miles, which is an85-mileoverage of the benefit. Based on this information, we decided that the Plan's rules for coverageof routine transportation have not been met.Therefore, we decided that the Plandoes not haveto pre-approveadditional mileage.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on November 14, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says non-emergent services rendered by non-participating providers in non-participating facilities require prior authorization as outlined in the enrollee's EOC.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 andpre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found noexception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on November 14, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF 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 was medically stable with no evidence of need for supervision by a physical medicine and rehabilitation (PMR) Physician or needs acute rehab nursing care. They may benefit from further physical therapy (PT) and occupational therapy (OT) but does not require an intensive therapy program. IRF admission is not medically necessary based on the enrollee's current functional status and medical stability.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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approveendovenous ablation.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that endovenous ablation is covered when specific criteria are met.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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the submitted records show that you have pain at an injection site consistent with vein inflammation (phlebitis). There are no recent arterial studies. It is not documented if you have had any improvement following the initial ablation procedures. There is no evidence of recent conservative treatment. Additionally, you have active phlebitis and it is not clear how much this is contributing to your leg pain. The requested endovenous ablation is therefore not reasonable or 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approveendovenous ablation
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve7 additional months of CPAP rental, beyond the 3 months approved by the Plan.You asked the Plan to pre-approvethe 7 additional months of CPAP rental. You say that the CPAP rental is medically necessary for the ten months being requested.The Plan denied your request. The Plan says the three month approval is sufficient and that the ten months being requested is not medically reasonable and necessary. The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Medicare rules also say that the continued coverage of a PAP device beyond the first three months of therapy requires that certain criteria have been met.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 7 additional months of CPAP rental. Our reviewer says that the 7 additional months of CPAP rental are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has severe obstructive sleep apnea, but has not been able to comply with regular usage of CPAP. Mask issues have since been addressed. The Plan has approved an additional 3 months of coverage to see if the enrollee is able to meet the minimum usage requirements of at least 4 hours per night for at least 70% of nights. This is a sufficient interval to establish compliance. Approval of an additional 7 months is not medically necessary at this time.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 7 additional months of CPAP rental have not been met.Therefore, we decided that the Plan does not have to pre-approve7 additionalmonths of CPAP rental, beyond the 3 months approved by the Plan.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to approvecontinued skilled nursing facility (SNF) services after March 15, 2020 for the enrollee.You asked the Plan to approveSNF care. You say that you disagree with the denial.The Plan denied your request. The Plan says that the services are not medically necessary.The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before the last covered day. This notice must include a description of the enrollee's right to an appeal.We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or more days before March 15, 2020. The NOMNC included in the documentation is blank. The Plan must pay for SNF services until the 100-day SNF care benefit is exhausted or daily skilled care is no longer needed and proper notice is issued. Therefore, we decided that the Plan has to approvecontinued skilled nursing facility (SNF) services after March 15, 2020 for the enrollee.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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forlab work provided on November 19, 2019 by an out of network (OON) provider.You asked the Plan to pay forlab work. You say that you would like this appeal reprocessed and approved for payment.The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that there are in-network providers available for these services.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 has network providers available who can provide 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 forlab work provided on November 19, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea tier exception for Novolog for the enrollee.You asked the Planto pre-approvethe exception. You say that a lower cost should be approved.The Plandenied your request. The Plansaystier exceptions are not available for Part B drugs.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 thePlan was correct in denying the request to pre-approve the exception. Our reviewer says that  Our physician reviewer found 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 exception have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea tier exception for Novolog for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee on November 19, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe OON services. You say that there was no other provider in the area.The Plan denied your request. The Plan says prior authorization was not obtained as required under the plan benefits.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 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 forthe medical services provided to the enrollee on November 19, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee on October 1, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe OON services. You say that the medical records show medical necessity.The Plan denied your request. The Plan says there is no valid referral for this service.Medicare rules say thatplans 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 has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the servicesat 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 forthe medical services provided to the enrollee on October 1, 2019 by an out of network (OON) provider
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forinfection agent detection by nucleic acid testing provided on September 6, 2019.You asked the Plan to pay forlaboratory testing. You say that you are appealing with medical records.The Plan denied your request. The Plan says the denial of payment for these services is correct, because these tests are experimental/investigational and are not the standard of care for testing in this case.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 pay for laboratory testing. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the submitted documentation does not include a history, physical, urinalysis result, history of resistance, or rationale for this molecular testing.We looked at this physician's review, the file, andMedicare rules. Based on this information, we decided that Medicare rules for coverage of laboratory testing have not been met.Therefore, we decided that the Plan does not have to pay forinfection agent detection by nucleic acid testing provided on September 6, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for an additional 30 minutes of critical care services (99292) provided on September 12, 2019.You asked the Plan to pay for the additional critical care services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the submitted code requires a preceding procedure code and cannot be reimbursed separately.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code the additional critical care services is an add-on code and has not been billed with the required primary procedure code. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to payfor an additional 30 minutes of critical care services (99292) provided on September 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea walk-in bathtub for the enrollee.You asked the Plan to pre-approvea walk-in bathtub. The Plan denied your request. The Plan says that this is not covered under Medicare or the Plan.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plan does not have to pre-approvea walk-in bathtub for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveOfev Cap 150mg for the enrollee.You asked the Plan to pre-approvethe drug. You say that this is medically necessary.The Plandenied your request. The Plan says this medication is covered under the Part D benefits, which the enrollee does not have.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approveOfev Cap 150mg for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay fordrug testing services provided to the enrollee on August 28, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthe records do not support the service billed.The Plan must follow Medicare rules. Medicare rules say that a physician order must be present for labs to be covered.The documentation submitted did not include a physician order/lab requisition or medical records stating exactly tests were to be performed. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plandoes not haveto pay fordrug testing services provided to the enrollee on August 28, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services (CPT 27380) provided to the enrollee on August 16, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the billed code is not supported.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 27380 is "Suture of infrapatellar tendon; primary".We asked our coding 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 reviewer says that the use of CPT 27380 is not supported by the records provided. Our coding reviewer found that the medical records provided do not include documentation of asuture of infrapatellar tendon; primary being performed on August 16, 2019. The appropriate description was not included in the operative report for services performed on August 16, 2019.We looked at this coder'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 forthe services (CPT 27380) provided to the enrollee on August 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on May 1, 2019.You asked the Plan to pay forthe services. You say that you are an in-network provider.The Plan denied your request. The Plan says the provider is out-of-network and the services were not authorized.Medicare rules say that plans can require enrollees to get care from network providers. Thecontract 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 has network providers available who can provide 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 forthe medical services provided to the enrollee by an out-of-network provider on May 1, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider from September 30, 2019, to November 18, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the services were not authorized.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 has network providers available who can provide 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 forthe medical services provided to the enrollee by an out-of-network provider from September 30, 2019, to November 18, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a chest x-ray (71045) provided by November 14, 2019.You asked the Plan to pay for the chest x-ray. You say that you would like reconsideration because the member had multiple exams on the same day. The Plan denied your request. The Plan says the documentation supports that multiple services were rendered but were not billed with an appropriate modifier.The Plan mustfollow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT code 71045is not supported in the record. Specifically, this code was not billed with an appropriate modifier to show that a repeat service was rendered by the same physician. Based on this information, we decided that Medicare rules for coverage of the chest x-ray have not been met. Therefore, we decided that the Plan does not have to pay for a chest x-ray (71045) provided by November 14, 2019.