Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acupuncture treatment (97810).You asked the Plan to pre-approve this service. You say that you are requesting reconsideration of the Plan's denial at the suggestion of your neurologist because you have peripheral neuropathy. The neuropathy causes numbness in your feet and affects your balance and ability to walk.The Plan denied your request. The Plan says acupuncture is not a covered benefit under your policy for any circumstance.The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare.The services at issue in this appeal are acupuncture services.Therefore, we decided that the Plan does not have to pre-approve acupuncture treatment (97810).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network mental health care provided on October 1, 2019.
You asked the Plan to pay for out of network providers. You say that this service should be covered by the Plan. The Plan denied your request. The Plan says you 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 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 service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for out of network mental health care provided on October 1, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveNitroglycerin sublingual tabs for the enrollee.You asked the Plan to pre-approveNitroglycerin. You say that the enrollee wishes to proceed with medical therapy without invasive procedures.The Plan denied your request. The Plan says the enrollee's medical plan does not cover outpatient prescription drugs.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The 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-approveNitroglycerin sublingual tabs for the enrollee. Benefits for Nitroglycerinmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fornutritional supplements coded as B4185, B4197, B4220 and B4224.You asked the Plan to pay forthe nutritional supplements. You say that the medical records provided will show proof of medical necessity.The Plan denied your request. The Plan says the records do not support the service billed.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  physician order for the supplies provided in this case.Therefore, we decided that the Plan does not have to pay fornutritional supplements coded as B4185, B4197, B4220and B4224
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) admission and services.You asked the Plan to pre-approveSNF services. The Plan denied your request. The Plan says you do not require close medical supervision as an inpatient.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 necessary. Our physician reviewer found that from a nursing perspective, you have stable vital signs. There are no identifiable skilled nursing service needs. Regarding rehab services, you are at a supervision level with functional mobility. You require varying assist with activities of daily living. Although there are identifiable skilled therapy service needs, you do not require skilled nursing or therapy services on a daily 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services to be provided by an out of network provider.
You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
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 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. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physician's services to be provided by the out of network provider.
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 you need SNF care to regain your strength and return home safely. The Plan denied your request. The Plan says your needs can be safely managed with 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 above 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 the records do not show that you have any identifiable skilled nursing service needs. While you do have skilled therapy needs, you do not need therapy services on a daily basis, nor do you require these services on 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 care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
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 the services are necessary. The Plan denied your request. The Plan says the enrollee can receive the care required at the current facility they are in. Therefore, coverage criteria has 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 the review indicates that the enrollee still requires acute level of care hospital services and is receiving appropriate care at the present acute care hospital. There is no documentation provided necessitating admission to a LTACH. The review has determined that the enrollee does not require services at the LTACH that are not available at the acute care hospital where they are 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 long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the brace provided on August 27, 2019 by an out of network (OON) supplier.
You asked the Plan to pay for the OON brace. You say that this was medically necessary. The Plan denied your request. The Plan says this was provided out of network without 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 nor was the ordering physician. 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 the brace provided on August 27, 2019 by an out of network (OON) supplier.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for occupational therapy services (G0152 and Q5001) provided on August 1, 2019.
You asked the Plan to pay for the occupational therapy services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the claim was not billed in accordance with CMS guidance regarding billing home health episodes without skilled services.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find that CPT codes G0152 and Q5001 are not supported in the record. Specifically, the claim was submitted without any skilled nursing services. Per CMS guidance, condition code 54 should be submitted on any home health claim without skilled nursing services. Based on this information, we decided that Medicare rules for coverage of the occupational therapy services have not been met. Therefore, we decided that the Plan does not have to pay for occupational therapy services (G0152 and Q5001) provided on August 1, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on August 14, 2019.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says the enrollee must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan
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 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 laboratory services provided on August 14, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve multifocal intraocular lenses (a type of advanced intraocular lens called Optilens).You asked the Plan to pre-approve Optilens. You say that standard intraocular lenses would require you to wear glasses, but you have trouble wearing glasses.The Plan denied your request. The Plan says the denial of authorization for these intraocular lenses is correct, because these intraocular lenses are not covered by Medicare.The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. The services you asked the Plan to pre-approve are considered routine vision services or eyewear.Therefore, we decided that the Plan does not have to pre-approvemultifocal intraocular lenses (a type of advanced intraocular lens called Optilens).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the glucose monitor, test strips, lancets, control solution, and lancet device provided from August 9, 2019 to October 28, 2019.
You asked the Plan to pay for the glucose monitor (E2100), test strips (A4253), lancets (A4259), control solution (A4256), and lancet device (A4258). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.
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 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. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered. Therefore, we decided that the Plan does not have to pay for the glucose monitor, test strips, lancets, control solution, and lancet device provided from August 9, 2019 to October 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an out-of-network cardiology consultation.You asked the Plan to pre-approvethe out-of-network cardiology consultation. The Plan denied your request. The Plan says the physician is not contracted in the enrollee's network. 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 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. 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-approvean out-of-network cardiology consultation
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the Computed Tomography (CT) of the Thorax (71250) provided on September 23, 2019 by out of network provider.
You asked the Plan to pay for the CT scan. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were not emergent and were not preauthorized. The enrollee had no out-of-network 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 has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the Computed Tomography (CT) of the Thorax (71250) provided on September 23, 2019 by out of network provider.
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 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 Medicare pays for care in a SNF when the four factors listed above 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 the enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does 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 care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Asmanex inhaler.You asked the Plan to pre-approve self-administered drugs. You say that you are appealing.The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.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-approve Asmanex inhaler.Benefits for self-administered drugs may be available under Medicare Part D.Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acupuncture treatments (97810).
You asked the Plan to pre-approve these services. You say that you are asking for an exception to the Plan's denial as there is no treatment or cure available for your disease. The Plan denied your request. The Plan says acupuncture is not a covered benefit under your policy for any circumstance.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. The services at issue in this appeal are acupuncture services. Therefore, we decided that the Plan does not have to pre-approve acupuncture treatments (97810).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device (HFCWOD).
You asked the Plan to pre-approve a HFCWOD. You say that you are appealing the denial to allow this medically necessary therapy as prescribed by her physician. The Plan denied your request. The Plan says based on the records the enrollee does not meet the requirements for approval.
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases. 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 HFCWOD. Our reviewer says that the request for the HFCWOD is not medically necessary for this enrollee. Our physician reviewer found the enrollee has severe, oxygen-dependent COPD. Bronchiectasis is listed as a diagnosis in some parts of the medical record, but there is no CT scan of the chest to document the diagnosis. A chest x-ray report does not mention bronchiectasis. The enrollee does not have cystic fibrosis or generalized neuromuscular disease. She therefore does not have a qualifying diagnosis. HFCWCD has not been shown to be beneficial in the treatment of COPD or chronic bronchitis. 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 HFCWOD have not been met. Therefore, we decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device (HFCWOD).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foremergency room visit provided by "the hospital" on August 11, 2019.You asked the Plan to waive the copayment foremergency room visit. You say that you do not agree with this copayment and you are not going to pay for it.The Plan denied your request. The Plan says the correct copayment has been applied.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharinginformation (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 copayment for emergency care. You have been asked to pay a $90 copayment for emergency room visit. Since an emergency room visit was provided, the correct copayment has been applied. Emergency room visit falls within the emergency care 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 foremergency room visit provided by "the hospital" on August 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a FreeStyle Libre continuous glucose monitoring system.
You asked the Plan to pre-approve a continuous glucose monitor. You say that the enrollee needs to have better glucose control and being able to check frequently without finger sticking would help. The Plan denied your request. The Plan says the enrollee is not testing four or more times a day or insulin injecting three or more times a day.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor. We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a FreeStyle Libre continuous glucose monitoring system.