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

We decided that the Plan does not have to waive the copayment forphysician services provided on July 22, 2020.You asked the Plan to waive the copayment forphysician services. You say that you didn'thave an appointment on this date. You say that you don't understand why you are being charged for a phone call.The Plan denied your request. The Plan says the copayment 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 $50 copayment for Medicare-covered physician specialist services. You have been asked to pay $44.42, which is less than the standard $50 copayment for the physician services. The physician services fall within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show that this was a telehealth visit. 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 forphysician services provided on July 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forpayment for a telehealth distant site service (G2025) provided on June 11, 2020.You asked the Plan to pay forthe payment for a telehealth distant site service. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says this claim has not been billed correctly.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
We find that CPT code G2025 is not supported in the record. Specifically, per Medicare guidance, CPT code G2025 has been billed without the required modifier. Based on this information, we decided that Medicare rules for coverage of the payment for a telehealth distant site service have not been met.Therefore, we decided that the Plan does not have to pay forpayment for a telehealth distant site service (G2025) provided on June 11, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forlab work provided on January 15, 2020 by an out of network (OON) provider.You asked the Plan to pay forlab work. You say that you would like this claim paid.The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the rendering facility is 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 forlab work provided on January 15, 2020 by an out of network (OON) provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on July 1, 2020.
You asked the Plan to pay for the domiciliary, rest home visit. 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 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 a domiciliary, rest home visit provided on July 1, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services for the enrollee.You asked the Plan to pre-approveIRF care. You say that the enrollee needs care to regain full function and independence.The Plan denied your request. The Plan says that the enrollee can safely receive the services needed in other settings.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. The complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for a COPD exacerbation. The enrollee's medical problems are stable. There are no identified problems that need inpatient medical management. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 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 patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve out of network evaluation and management services.
You asked the Plan to pre-approve the out of network evaluation and management services. You say that the enrollee has been an established patient with the out of network provider since 2011. You say that the enrollee has been approved for infusions with the out of network provider, but not the office visit. The Plan denied your request. The Plan says there are plan providers who are available to provide the service being requested.
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet the enrollees' needs. The enrollee's contract with the Plan says that, with few exceptions, enrollees 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 out of network evaluation and management services. Our reviewer says that the criteria for coverage of out of network care have not been met. Our physician reviewer found the enrollee has Rheumatoid arthritis with rheumatoid factor of multiple sites without organ or systems involvement, and chronic pain. The enrollee's condition is noted to be under good control on November 19, 2020. The enrollee is not currently receiving any active treatment and/or
medical management of the condition that makes it medically necessary to continue care with the out of network provider as requested. There is no unique aspect of the enrollee's condition that would make it medically necessary for her to continue care with the out of network provider. The Plan has shown that they have in-network specialists who have the qualifications and expertise necessary to meet the current medical Standards of Care required for treatment of the enrollee's condition. The documentation supports that the enrollee's medical management and/or follow-up care can be safely transitioned to an in-network specialist 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 out of network evaluation and management services have not been met. Therefore, we decided that the Plan does not have to pre-approve out of network evaluation and management services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your
request. The Plan says the services can be safely received in other settings, for example: a skilled nursing
facility.
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 you do not require the intensity of services provided at an IRF. Specifically, you are
not shown to be able to perform fifteen hours per week of rehabilitative services with regular physician
evaluation. Your care needs can be met at a lower level of care (ex. SNF/SAR)
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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient care provided on December 26, 2019.
You asked the Plan to waive the copayment for inpatient care. You say that you were transported to another hospital. You say that you feel that you should only pay the $80 copayment for the emergency room. The Plan denied your request. The Plan says the copayment 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 $345 per day, per admission for days 1-5 for covered hospital stays. You have been asked to pay a $345 copayment for inpatient care. Inpatient care falls within the "Inpatient hospital care" benefit category. The records show that you were treated and admitted as an inpatient. 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 inpatient care provided on December 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided  that the  Plandoes not haveto pre-approvea full-size  bariatric  high  low  air  mattress  bed with trapeze.You asked the Planto pre-approvethe bed. You  say that this  is medically  necessary.The Plandenied  your request. The  Plansaysthere  is  no new  medical  diagnosis  that  would  require  a new  bed and trapeze.
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 bed. Our reviewer  says  that  the requested  services  are not  considered  medically  reasonable  and necessary  in  this  case. Our physician  reviewer found  there  is  no documentation  of  stage 3 (full  thickness  tissue  loss)  or stage 4 (deep tissue  destruction) pressure  sores.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  bed have  not  been met.Therefore,  we decided that the  Plandoes not haveto pre-approvea full-size  bariatric  high  low  air  mattress  bed with  trapeze.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided  that  the  Plan  does not  have to pre-approveSteroid  Back Injection.You asked the  Plan to pre-approveSteroid  Back Injection.  You say  that you  would  like  the plan  to reconsider their  denial.The  Plan  denied  your  request.  The  Plan  says the  requested  services  are not medically  necessary.The  Plan  must  follow  Medicare  rules.  Medicare  rules  say  that  items  and  services  that  arenot 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  Steroid  Back Injection.  Our reviewer says  that  the requested  items/services  are not considered  medically  reasonable  and necessary  in  this  case. Our physician  reviewer  found  the enrollee  has chronic  neck pain  and has received  prior  physical  therapy,  NSAID therapy  and a cervical  epidural  steroid  injection.  The  documentation  does not  adequately  address the  degree and duration  of  pain  relief  from  the  prior  injection.  Therefore,  the  request  is  considered  not medically reasonable  or necessary  at this  point.Review  of the  file  shows  that  the  plan  uses  Local  Coverage  Determination  (LCD)  L35456 and Local  Coverage Article  (LCA)  A56034 to support  their  denial.  However,  these  documents  are not  valid  for the  enrollee's  home state of  Georgia.  Therefore,  we are unable  to use these  rules  to substantiate  our decision.We looked  at this  physician's  review,  the  file,  and  Medicare  rules.  Based on this  information,  we decided that Medicare  rules  for coverage  of Steroid  Back Injection  have  not been met.Therefore,  we decided  that  the Plan does not  have to pre-approveSteroid  Back Injection.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pay forthe occupational therapy services provided on July 17,2020.You asked the Plan to pay forthe services provided. The Plan denied your request. The Plan says that the allowed amount limit for occupational therapy has been reached.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.You were referred for the services at issueby a contract provider. The file does not show that the Plan provided notice that would not be covered. Under Medicare rules, this means the services are considered approved by the Plan.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Therefore, we decided that the Plan has to pay forthe occupational therapy services provided on July 17, 2020.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 toopen the case again, we will send you a letter
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an open MRI.
You asked the Plan to pre-approve the MRI. You say that this is needed prior to an orthopedic surgical
evaluation. The Plan denied your request. The Plan says there is no documentation of an attempt and failure at
a wide bore MRI, as required.
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 the MRI. Our reviewer says that the
requested MRI is not medically reasonable or necessary. Our physician reviewer found apparently, you had a
previous wide bore MRI study in 2014. Whether sedation was required for that exam is unclear. You were
scheduled for a wide bore MRI on 10/14/20, but you failed to keep the appointment. Before you are sent for an
out-of-network open MRI, you should at least attempt a wide bore MRI exam. Such exams commonly are done
on patients with claustrophobia using anti-anxiety meds or light conscious sedation. There is no
contraindication to at least attempting a wide bore examination and in particular it appears you had a study
using a wide bore machine in 2014.
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 MRI have not been met. Therefore, we decided that the Plan does not have
to pre-approve an open MRI.
Appeal type: Supplemental Benefit
Decision: Unfavorable

e decided that the Plan does not have to pay for palliative dental services (D9110) provided.

You asked the Plan to pay for palliative dental services. You say that the services was medically necessary.The Plan denied your request. The Plan says the enrollee never selected the optional supplemental benefit and only has coverage for Medicare-covered dental services. The dental services that the enrollee received did not fall into the category of Medicare-covered dental services Medicare generally does not cover dental services. 

The Plan follows the same rule.The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare.Therefore, we decided that the Plan does not have to pay for palliative dental services (D9110) provided
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe comprehensive oral evaluation (D0150) provided on August 5, 2020.You asked the Plan to pay forthe comprehensive oral evaluation. You say that you have not had a cleaning since last November.The Plan denied your request. The Plan says this service exceeds the frequency limitation in your benefit plan.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, comprehensive oral evaluation (D0150) is limited to one procedure every three plan years. The record shows that you received a comprehensive oral evaluation (D0150) on November 19, 2019, and your comprehensiveoral evaluation (D0150) benefit has been exhausted.Therefore, we decided that the Plan does not have to pay forthe comprehensive oral evaluation (D0150) provided on August 5, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided  that  the  Plan  does not  have to pay  foroutpatient  mental  health  care provided  to the  enrollee  from February  14, 2020 to July  17, 2020.You asked the  Plan to pay  forthis  service.  You say  that this  claim  should  be paid.The  Plan  denied  your request.  The  Plan  says the enrollee  did  not have  prior  authorization  for  out of network  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  contract  also states  outpatient  mental  health  care requires prior  authorization.  The provider  in  this  case is  not a network  provider  with  the  Plan.  The  Plan  did not  pre-approve  these services. 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 foroutpatient  mental  health  care provided  to the enrollee  from  February  14, 2020 to July  17, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips for the enrollee.

You asked the Plan to pre-approve additional routine transportation trips. You say that the enrollee needs to get to dialysis treatment three times a week.The Plan denied your request. The Plan says that the enrollee has exhausted this 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 a maximum of thirty-six (36) trips per year. 

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation.Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approveendodontic therapy (D3320) and a cone beam three-dimensional image (D0363).You asked the Plan to pre-approvethe endodontic therapy and the cone beam three-dimensional imaging. You say that your general dentist referred to you and endodontist who confirmed that you have a massive infection in the bone and above teeth #2 and #4. You say that the endodontist advised you that you need a root canal and better imaging of the current dental problem. You say that you have two heart valve issues and your cardiologist advised that this type of periodontal infection could migrate to the heart and cause major problems.The Plan denied your request. The Plan says the benefit limit for root canal services has been exhausted for the 2020 plan year. The Plan says that the cone beam three-dimensional imaging is not a covered benefit.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, cone beam three-dimensional imaging is not among these benefits. Coverage of a root canal is, but this benefit is limited to one procedure per calendar year. The records show that you were approved for a root canal on December 4, 2020. This would be the only coverage of a root canal allowed for the 2020 calendar year.Therefore, we decided that the Plan does not have to pre-approveendodontic therapy (D3320) and a cone beam three-dimensional image (D0363).