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

We decided that the Plandoes not haveto pre-approvean upper endoscopy.You asked the Planto pre-approvethe endoscopy. You say that you want to follow the request of your specialist to complete this annually.The Plandenied your request. The Plansaysthere is not enough information to show why this test is needed.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 pre-approve the endoscopy. Our reviewer says that the requested endoscopy is not considered medically reasonable and necessary in this case. Our physician reviewer found you have GI symptoms, other than occasional positional right abdominal discomfort. You have no GI hemorrhage, no upper GI cancer, and no Barrett's esophagus to warrant this frequency of endoscopic examination.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 endoscopy have not been met.Therefore, we decided that the Plandoes not haveto pre-approvean upper endoscopy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe limited oral evaluation (D0140) provided on June 16, 2020.You asked the Plan to pay forthe dental service. You say that you do not understand why the service was denied. You say that you were advised you would lose some of your teeth if the procedure was not done. You say that you ended up needing implants. You say that you do not feel like you are exceeding anything.The Plan denied your request. The Plan says 1 limited oral evaluation is covered every plan year. The Plan also says that the frequency limit for this service 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, the frequency limit of 1 limited oral evaluation per year has been exceeded. The record shows that the Plan paid for a limited oral evaluation that you received on June 13, 2020.Therefore, we decided that the Plan does not have to pay forthe limited oral evaluation (D0140) provided on June 16, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay forpsychotherapy services provided on June 9, 2020 by an out of network (OON) provider.You asked the Plan to pay forpsychotherapy services. You say that you would like this claim reprocessed and approved for payment. You say that these services are provided in good faith.The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the referring outpatient nursing facility 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 forpsychotherapy services provided on June 9, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea continuous positive airway pressure (CPAP) device rental.You asked the Plan to pre-approvea CPAP device rental. 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 follows Medicare rules. Medicare rules say that continued coverage of a PAP device is covered when specific criteria is 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 a CPAP device rental. Our reviewer says that the item is not medically necessary. Our physician reviewer found based on the medical records provided there is no documentation that the enrollee meets the coverage criteria. Available medical records indicate the enrollee's compliance with using the PAP greater than or equal to 4 hours per night has ranged between 40% and 57% since August 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Victory Pride 9.2 scooterYou asked the Plan to pre-approve the Victory Pride 9.2 scooter. The Plan denied your request. The Plan says the submitted documentation does not confirm that the enrollee does not have sufficient upper extremity function to self-propel an optimally configured manual wheelchair in the home to perform MRADLs during a typical day. The documentation does not indicate that the enrollee's mobility in the home is unable to be helped by a manual wheelchair. It does not indicate that the enrollee's home provides adequate access between rooms, maneuvering space, and surfaces for the operation of the power operated vehicle if it is provided.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. 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 Victory Pride 9.2 scooter. Our reviewer says that the power mobility scooter is not medically necessary.Our physician reviewer found that the requested power mobility scooteris not medically necessary per Medicare National Coverage Determinations Manual, Section 280.3(B).The documentation doesreveal that the enrollee has a personal mobility deficit but it is not clear that the deficit impairs participation in MRADLs in the home or why the enrollee's mobility deficit is unable to be helped by a manual wheelchair. There is no detailed bilateral upper extremity neuromuscular exam indicating deficits that would not allow the use of a manual wheelchair. The documentation revealsno in person assessment of the enrollee's home to evaluate that she can safely maneuver the PMD within the home to perform MRADLs.
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 Victory Pride 9.2 scooter have not been met. Therefore, we decided that the Plan does not have to pre-approve aVictory Pride 9.2 scooter.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the emergency department visits (99284)
provided on July 22, 2020 and August 27, 2020.
You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to
the services provided.
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 $90
copayment for Medicare-covered emergency room visits.
You have been asked to pay $180 ($90 copayment x 2) for the emergency room visits provided. 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 copayments for the emergency department visits (99284) provided on July 22, 2020
and August 27, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar spine MRI.
You asked the Plan to pre-approve a lumbar spine MRI. You say that the requested lumbar spine MRI is medically necessary. The Plan denied your request. The Plan says the requested lumbar spine MRI is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. 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 lumbar spine MRI. Our reviewer says that the requested lumbar spine MRI is not medically necessary. Our physician reviewer found this enrollee presents with complaints of grade 7-10/10 low back and bilateral lower extremity pain. Functional limitations are noted in standing, walking and driving. Pain disrupts sleep. Clinical exam findings have documented tenderness to palpation and muscle tension in the lumbosacral spine. She has failed to improve with ice, heat, and medications. Under consideration is a request for lumbar spine MRI. Current evidence based medical literature/guidelines would not support MRI at this time. There is no documentation of any focal neurologic deficit to support a diagnosis of lumbar radiculopathy. Given the absence of physiologic evidence of tissue insult or neurologic dysfunction, progressive neurologic symptoms, or failed physician-directed conservative treatment, the request for lumbar spine MRI is not medically reasonable and 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 a lumbar spine MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve a lumbar spine MRI.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on July 28, 2020.
You asked the Plan to pay for the subsequent nursing facility care. You say that the enrollee was not in hospice at the time of service. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.
The enrollee ended Medicare Hospice benefits on July 5, 2020. The services in question were provided before the end of that month.
Therefore, we decided that the Plan does not have to pay for subsequent nursing facility care provided on July 28, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspirate (20939).
You asked the Plan to pre-approve bone marrow aspirate. You say that the services are necessary. The Plan
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has
not been met.
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 pre-approve bone marrow aspirate. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found bone marrow aspirate remains experimental in cases of spinal fusion. More research
is needed.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of bone marrow aspirate have not been met. Therefore, we decided that the Plan
does not have to pre-approve bone marrow aspirate (20939).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the specialty services provided on June 24, 2020 by an out of
network provider.
You asked the Plan to pay for the specialty service. You say that the Plan should pay this claim. The Plan
denied your request. The Plan says prior authorization for this service was not obtained.
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 the specialty services provided on June 24, 2020
by an out of network 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 the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.
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 enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for mental status changes. He was treated for urinary tract infection and shingles. Medical problems are stable. There are no identified problems that need inpatient medical management. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, in an intensive rehabilitation therapy program. The medical record supports a need for physical and occupational therapy but it does not support a need for an intensive rehabilitation therapy program. There is not a reasonable expectation that this enrollee 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on August 5, 2020.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 Plan did not pre-approve the laboratory services. 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 laboratory services provided on August 5, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe subsequent nursing facility care provided on June 2, 2020,by an OON provider.You asked the Plan to pay forsubsequent nursing facility care. You say that you received payment for services rendered by this provider without authorization for this same enrollee for a March 3, 2020 date of service.The Plan denied your request. The Plan says the service was rendered by an OON provider, without prior authorization. The Plan also says that the provider failed to contact the Plan to verify insurance, current eligibility, or authorization requirements.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 forthe subsequent nursing facility care provided on June 2, 2020, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on May 19, 2020.
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 for subsequent nursing facility care provided on May 19, 2020.
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 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 based on the medical records provided the complexity of your nursing, medical and
rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to
rehabilitation care. You do require physical therapy and occupational therapy services but you do not require an
intensive inpatient rehabilitation therapy program. There is concern that you will not be able to fully participate
in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility
due to your functional limitations. Care at the skilled nursing facility level appears to be more appropriate in
this case.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services (D0350, D5225, D5226) provided February 6, 2020.
You asked the Plan to pay for the dental services. You say that you would like the Plan to review and reprocess these claims for payment. The Plan denied your request. The Plan says the dental services denied are not covered benefits under the Plan's supplemental dental coverage.
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 dental services (D0350, D5225, D5226) provided February 6, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the SNF care provided from February 6, 2020, to March 26, 2020.
You asked the Plan to waive the copayment for the SNF care. You say that it was court ordered that the Plan is responsible for any of the costs incurred, and you do not owe anything for the February or March dates of service. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.
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 $0 copayment per day for days 1 to 20, and a $178 copayment per day for days 21 to 100 for SNF care. This stay lasted 39 days, resulting in a total copayment amount of $3,382. You have been asked to pay $0 copayment per day for days 1 to 20, and a $178 copayment per day for days 21 to 100 for the SNF care. SNF care falls within the Skilled Nursing Facility (SNF) 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 for the SNF care provided from February 6, 2020, to March 26, 2020.