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

We decided that the Plan does not have to pay for skilled nursing services provided on November 5, 2019 by an out of network (OON) provider.You asked the Plan to pay for skilled nursing services. You say that since the member was in a nursing facility, the doctor was not responsible to get authorization.The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the referring 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 for skilled nursing services provided on November 5, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient care provided from October 2, 2019 to October 5, 2019.
You asked the Plan to pay for inpatient care. You say that this was medically necessary. The Plan denied your request. The Plan says the enrollee was stable for transfer to a plan facility prior to admission.
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for inpatient care. Our reviewer says that the services at issue are post-stabilization care and the criteria for coverage have not been met. Our physician reviewer found the documentation does not contain any declarations of stability or instability for transfer. The enrollee could have been safely transported to a plan facility for continuing care without an expected decline in his condition. Any care provided after the decision to admit the enrollee is post-stabilization care and is not covered unless pre-authorized by the health plan. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient care have not been met. Therefore, we decided that the Plan does not have to pay for inpatient care provided from October 2, 2019 to October 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple power options.
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied your request. The Plan says there is no medical need for which the power recline is needed.
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 rules say also that a group three power wheelchair with multiple power options is covered if there is a specific mobility limitation, and if there a medical necessity for a power tilt and/or recline. 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 wheelchair. Our reviewer says that the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found the records do not suggest that the enrollee is incapable of ambulating with a walker or a lightweight wheelchair. The records do not indicate that the enrollee is incapable of self-pressure relief, so the tilt feature is therefore a convenience item. There is no evidence of a mobility limitation due to a neurological condition, myopathy, congenital skeletal deformity, etc. 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 wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple power options.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eight additional physical therapy (PT) visits.
You asked the Plan to pre-approve the additional visits. You say that the enrollee benefits from the sessions. The Plan denied your request. The Plan says the PT services are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 additional visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that the requested therapy is generally not accepted as specific and effective therapy for the enrollee's condition. The enrollee has had extensive prior therapy visits and the documentation does not reveal evidence that an additional eight visits are necessary by a professional therapist. The records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist beyond what was already approved. The enrollee has been instructed in a home exercise program. The requested services are not part of a maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. 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 additional visits have not been met. Therefore, we decided that the Plan does not have to pre-approve eight additional physical therapy (PT) visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on May 1, 2019 to July 24, 2019 by a non-Medicare provider.
You asked the Plan to pay for the services provided. You say that previous claims were processed and paid by the plan. The Plan denied your request. The Plan says the claim denied correctly as you received services from a non-Medicare certified provider.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that you receive care from a provider who is eligible to provider services under Original Medicare. The requested provider in this case is not a provider who is eligible to provide services under Original Medicare. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the medical services provided on May 1, 2019 to July 24, 2019 by a non-Medicare provider.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approvehearing aid (V5298) and ear mold/insert (V5264).You asked the Plan to pre-approve the hearing aids and molds. You say that you are not able to hear when people are talking to you and you need the hearing aids.The Plan denied your request. The Plan says that the hearing aids and molds do not meet the criteria.Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan pays for hearing aids only when considered 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 hearing aids and molds. Our reviewer says that this enrollee meets the criteria for the hearing aids. Our physician reviewer found the criteria states the patient should have a hearing threshold 40dB HL or greater at 500, 1000, 2000, 3000, or 4000 Hz or hearing thresholds 26dB HL or greater at three of these frequencies or speech recognition less than 94 percent. Based on the new criteria given, the enrollee meets the criteria for obtaining a hearing aids.We looked at this physician's review, the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aids and molds have been met.Therefore, we decided that the Plan has to pre-approvehearing aid (V5298) and ear mold/insert (V5264).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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay formedical nutritional therapy services provided on October 2, 2019.You asked the Plan to pay formedical nutrition therapy services. You say that the nutritional therapy services were medically necessary and appropriate.The Plan denied your request. The Plan says medical nutrition therapy services are covered by Medicare only for diabetes and renal disease.The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services only for enrollees with renal disease or diabetes. Records do not show that the enrollee suffers from renal disease or diabetes.Therefore, we decided that the Plan does not have to pay formedical nutritional therapy services provided on October 2, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee on March 4, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. The Plan denied your request. The Plan says there is no network deficiency for the services, and alternate network providers were found.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these OON services. Therefore, we decided that the Plan does not have to pay for the medical services provided on March 4, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee on October 31, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were provided during an inpatient stay.
The Plan must follow Medicare rules. Medicare rules say that the inpatient POS code must be reported by services provided during an inpatient stay. We looked at the file and Medicare rules. The records provided show that the enrollee was an inpatient at the time the services in question were provided. The outpatient POS code is inappropriate to use when billing services provided during an inpatient stay. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services provided to the enrollee on October 31, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from June 29, 2019 through July 10, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The Plan denied your request. The Plan says that the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (ED) and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from June 29, 2019 through July 10, 2019.
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: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve core buildup, including any pins when required, for tooth #18, and
a crown for tooth #18.
You asked the Plan to pre-approve the core buildup for tooth #18 and crown for tooth #18. The Plan denied
your request. The Plan says that the services are not medically necessary due to poor prognosis.
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. The Plan covers the core
buildup for tooth #18 and crown for tooth #18 when the services are medically necessary and reasonable.
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 core buildup for tooth #18 and crown for tooth #18. Our reviewer says that these services
meet the criteria for coverage. Our physician reviewer found due to the large restoration and recurrent caries
and/or fracture, a core buildup is reasonable to provide the adequate support and retention for a crown which
would restore tooth #18 to good functional occlusion.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
the Plan's rules for coverage of the core buildup for tooth #18 and crown for tooth #18 have been met.
Therefore, we decided that the Plan has to pre-approve core buildup, including any pins when required, for
tooth #18, and a crown for tooth #18.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a neuromuscular electrical stimulator/functional electrical stimulator.You asked the Plan to pre-approve the stimulator. You say that this is medically necessary.The Plan denied your request. The Plan says the enrollee has multiple sclerosis, and not a spinal cord injury.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 stimulator. Our reviewer says that the requested stimulator is not considered medically reasonable and necessary in this case. Our physician reviewer found this is being prescribed to help with walking difficulties related to a diagnosis of multiple sclerosis. This technology is only covered for patients with a history of spinal cord injury who have undergone surgery. There is no history of spinal cord injury 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 the stimulator have not been met.Therefore, we decided that the Plan does not have to pre-approve a neuromuscular electrical stimulator/functional electrical stimulator.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on October 30, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on October 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forskilled nursing services provided on June 26, 2019 to July 2, 2019 by an out of network (OON) provider.You asked the Plan to pay forskilled nursing services. You say that these services were performed in a skilled nursing facility. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says no prior authorization was obtained for these services.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent careand 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 forskilled nursing services provided on June 26, 2019 to July 2, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveOrthovisc injections for the enrollee.You asked the Planto pre-approvethe injections. You say that this is medically necessary.The Plandenied your request. The Plansaysthe use of this medicine is not helpful in treating knee pain.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 injections. Our reviewer says that the requested injections are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no evidence of a trial and failure of conservative treatments. The review has determined that the enrollee does not meet criteria for the requested intra-articular injections of the left knee. The service at issue in this case is not medically reasonable and necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the injections have not been met.Therefore, we decided that the Plandoes not haveto pre-approveOrthovisc injections for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for physician services provided on May 22,
2019.
You asked the Plan to waive the coinsurance for physician services. You say that you think you consulted the
Plan prior to seeing the doctor. You say that you were informed you were covered. The Plan denied your
request. The Plan says the coinsurance 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 50% of
the Medicare-allowed amount for each out-of-network primary care provider visit for Medicare-covered
services.
You have been asked to pay $145.63, which is 50% of the allowed amount for physician services. The allowed
amount is $291.31 (50% x $291.31 = $145.63). Physician services falls within the "Physician/Practitioner
services, including doctor's office visits" benefit category. The records show that the provider is out-of-network.
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 coinsurance for physician services provided on May 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the facet joints.
You asked the Plan to pre-approve the RFA procedure. You say that your provider ordered this for you and
should know what is best for his patients. The Plan denied your request. The Plan says you have not met the
Medicare criteria for the requested procedure.
The Plan must follow Medicare rules. Medicare rules say that RFA of the facet joints only can be covered after
two MBBs which produce at least 80% pain relief.
In this case, the documentation submitted does not show that any MBBs have been provided on the right side at
the levels being requested. Without two MBBs showing that this nerve area is the pain generator, RFA of the
nerve is not covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve
radiofrequency ablation (RFA) of the facet joints.