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

We decided that the Plan does not have to pay for the laboratory services provided on September 28, 2019 by an out-of-network provider.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services were rendered by a non-networkprovider 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 requested provider in this case is not a network provider with the Plan. The referring provider is not a network provider with the Plan. The Plan has network providers available who can provide theitems/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 forthe laboratory services provided on September 28, 2019 by an out-of-network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.You asked the Plan to pay forthe ambulance services. You say that the services should be covered.The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on September 29, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay forthe ambulance services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory and chemotherapy services provided on July 11, 2019 by out of network provider.You asked the Plan to pay forthe laboratory and chemotherapy services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services rendered are not a covered benefit.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 doesnot have to pay forthe laboratory and chemotherapy services provided on July 11, 2019 by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe transthoracic echocardiography provided on September 25, 2019.You asked the Plan to waive the copayment forthe transthoracic echocardiography. You say that you were told there would be no member responsibility for this service. You say you have paid $20.00 in the past for the same service.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 $125 copayment for diagnostic tests and procedures at an in-network outpatient hospital. You have been asked to pay a $125 copayment for the transthoracic echocardiography. The transthoracic echocardiography falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows you were billed by the outpatient hospital.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 forthe transthoracic echocardiography provided on September 25, 2019.Our decision is only about the September 2019 service. If you have any questions about prior years billing, please contact the plan directly.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the records provided support the need for IRF care.The Plan denied your request. The Plan says that the enrollee is not currently stable for transfer to an IRF, as his heart rate is elevated and he is being evaluated for a pacemaker placement.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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer found the enrollee has multiple complex medical conditions. There would be an expected need to modify the enrollee's treatment in order to maximize his capacity to benefit from rehabilitation. Physician supervision at an acute rehabilitationlevel of care is required. The enrollee requires physical therapy for mobility and occupational therapy for remaining activities of daily living and adaptive equipment. A speech therapy evaluation is indicated for assessing and treating impairments of cognition. The enrollee is ambulating less than household distances and requires an intensive rehabilitation therapy program. The enrollee's medical conditions appear stable and he is participating in the treatments being provided. He had previously been independent supporting the expectation that he will improve and be able to return to the community. The enrollee would be expected to be able to fully participate in and benefit from the required intensity of an acute rehabilitation therapy program.We lookedat this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have been met.Therefore, we decided that the Plan has to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home visit services provided on February 23, 2019 by the out of network provider. You asked the Plan to pay forthe home visit services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the servicesrendered are not a covered benefit.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 forthe home visit services provided on February 23, 2019 by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvemedial branch blocks (MBBs).You asked the Plan to pre-approvethe medical branch blocks. You say that the enrollee received 50% relief for the first MBB, but will probably not have complete relief based on the amount of symptoms she has in other locations. You say that you would be pleased with the results if the enrollee's pain was cut by 50%.The Plan denied your request. The Plan says the requested injection services are not medically reasonable and necessary.The Plan follows Medicare rules. Medicare rules say that repeat MBBs are covered when the prior blocks provided at least 80% relief of the primary or index pain.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 medical branch blocks. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee has headaches, chronic neck pain, and chronic shoulder pain. The enrollee received bilateral C7-T1 diagnostic MBBs and achieved 50% pain relief. The repeat block is not considered medically reasonable or necessary because the requirement for at least 80% pain improvement have not been met.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverageof the medical branch blocks have not been met.Therefore, we decided that the Plan does not have to pre-approvemedial branch blocks (MBBs).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bath rail or a raised toilet seat.
You asked the Plan to pre-approve a bath rail and a raised toilet seat. You say that because of your medical condition you need a bath rail and a raised toilet seat. The Plan denied your request. The Plan says these items are not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that grab bars and raised toilet seats are not covered because they are not primarily medical in nature. While a grab bar and raised toilet seat may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve a bath rail or a raised toilet seat.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for diabetic supplies (A4253 and A4259) provided on October 2, 2019 through December 1, 2019.
You asked the Plan to pay for the diabetic supplies. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted did not include an itemized shipping/billing invoice to indicate the specific supplies, or proof of delivery indicating the specific items delivered from the billing provider.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.
The record shows that the Plan made several attempts to obtain the physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. Specifically, the submitted records include a delivery that was made on July 12, 2019. This does not reflect the date of service at issue and the supplies cannot be verified. Therefore, we decided that the Plan does not have to pay for diabetic supplies (A4253 and A4259) provided on October 2, 2019 through December 1, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that because of your medical condition you have a leg length and foot size discrepancy and need custom orthotics. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the home ventilator supplies provided on July 16, 2019.
You asked the Plan to pay for the full face mask (A7030), tubing (A7037), and filters (A7038, A7039). You say that the Plan should pay this claim. The Plan denied your request. The Plan says there is no physician order for the home ventilator supplies.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the physician order for the items at issue in this appeal. The record does not contain a valid physician order for the supplies provided in this case. Therefore, we decided that the Plan does not have to pay for the home ventilator supplies provided on July 16, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forthe facet joint injections provided on August 27, 2019 and September 23, 2019.You asked the Plan to waive the copayments forthe facet joint injections. You say that you only had injections. You say that you did not have surgery.The Plandenied your request. The Plan says the copayments applied 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 $295 copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital.You have been asked to pay a $295 copayment for each facet joint injection. The total amount you owe is $590 ($295/injection x 2 injections = $590). The facet joint injections fall within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. The facet joint injections are considered a surgical procedure. 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 Plandoes not have to waive the copayments forthe facet joint injections provided on August 27, 2019 and September 23, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy to be provided by an out of network provider.
You asked the Plan to pre-approve physical therapy. You say that you would like this physical therapy approved for your mother. The Plan denied your request. The Plan says 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 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 physical therapy to be provided by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a radiation/oncology specialist consultation at a tertiary level of care facility.
You asked the Plan to pre-approve the consultation at a tertiary facility. You say that treatment with the in-network lower level of care provider has not been successful and you would like to consult with the provider. The Plan denied your request. The Plan says a consultation at a tertiary level of care is not medically necessary and that in-network provider is able to supply the consultation services needed.
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care. 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 consultation at a tertiary facility. Our reviewer says that the criteria for out-of-network care have not been met. Our physician reviewer found the plan's denial is medically justified on the basis that it is offering adequate care to meet the enrollee's medical needs through referral to a non-tertiary level of care provider.
There is nothing unique about the enrollee's condition that would make it medically necessary for her to see the requested out-of-network tertiary level of care provider. Meningioma can be treated by in-network providers. The Plan has shown that thy have in-network non-tertiary level of care providers who meet the Standards of Care required for treatment of the enrollee's condition. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the consultation at a tertiary facility have not been met. Therefore, we decided that the Plan does not have to pre-approve a radiation/oncology specialist consultation at a tertiary level of care facility.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the core build up (D2950).
You asked the Plan to pre-approve the core build up. The Plan denied your request. The Plan says core build up is not a covered service.
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, core build up is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the core build up (D2950).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a pneumatic compression device from the provider.
You asked the Plan to provide a Flexitouch pneumatic compression device (E0652). You say that the enrollee had poor results with a basic and now needs the Flexitouch device. The Plan denied your request. The Plan says the record shows a single event trial with a basic pump.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to provide a pneumatic compression device from the provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 1 standard power operated vehicle.
You asked the Plan to pre-approve a scooter. You say that you are in pain and need a scooter. The Plan denied your request. The Plan says criteria for a scooter have not been met.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The assessment shows that you are a functional ambulator with the use of a cane or four-wheeled walker with a seat and you do not have a mobility deficit that impairs your participation in MRADLs. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 1 standard power operated vehicle.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient lab work provided on September 9, 2019.
You asked the Plan to pay for outpatient lab work. You say that the practice was not aware of the requirement of obtained a prior authorization. The Plan denied your request. The Plan says no prior authorization was obtained for these services. The Plan says that the referring provider is also out-of-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 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 for outpatient lab work provided on September 9, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a pneumatic compression device and appliances.
You asked the Plan to provide a Flexitouch pneumatic compression device (E0652) and appliances (E0667). You say that the enrollee tried to use a basic pump but this exacerbated the swelling. The Plan denied your request. The Plan says the records do not show the enrollee had a four week trial of a basic pump.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to provide a pneumatic compression device and appliances.