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

We decided that the Plan does not have to pay forthe additional mileage provided during an ambulance transport on April 9, 2020.You asked the Plan to pay forthe additional mileage. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services received are not a covered benefit.Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules. We looked at the file and Medicare rules. Review of the file shows that you receivedambulance services on April 9, 2020. The closest facility was 8.2 miles away. You elected to do go to a different facility that was further away. Medicare only covers emergency ambulance transportation is covered to the closest, most appropriate place forcare. This means that you are responsible for the different in mileage from the closest facility to the facility you elected to go to instead. Based on this information, we decided that Medicare rules for coverage of the additional mileage have not been met.Therefore, we decided that the Plan does not have to pay forthe additional mileage provided during an ambulance transport on April 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you forthe bedside commode purchased on June 10, 2020 the portable walker purchased on June 15, 2020.You asked the Plan to reimburseyou forthe bedside commode and portable walker. You say that the items were medically necessaryand needed immediately.The Plan denied your request. The Plan says you obtained durable medical equipment from a provider who does not participate withMedicare.The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items provided directly by a provider who is not eligible to take Medicare payment.  The items at issue in this appeal were provided by a provider not certified by Medicare.Therefore, we decided that the Plan does not have to reimburse you forthe bedside commode purchased on June 10, 2020 the portable walker purchased on June 15, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
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 the complexity of your nursing, 
medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. You were admitted for surgery for an ankle fracture. Medical conditions are 
stable. There are no medical needs requiring inpatient admission. There are no complex nursing or 
rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a 
need for physical and occupational therapy, it does not document a need for an intensive rehabilitation 
program. There is not a reasonable expectation that you 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 IRF admission and services.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pay for physical therapy services provided from August 4, 2020, to August 13, 
2020. 
 
You asked the Plan to pay for physical therapy services. You say that this was medically necessary. The Plan 
denied your request. The Plan says that the enrollee's therapeutic benefit had plateaued. 
 
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 pay for physical therapy services. Our reviewer says 
that the services at issue meet criteria for coverage. Our physician reviewer found the records demonstrate that 
the unique skills of a professional therapist were required to safely and effectively provide treatment, that the 
services can be safely and effectively performed only by a therapist, or for physical therapy and occupational 
therapy, by or under the supervision of a therapist and that this treatment was medically 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 physical therapy services have been met. Therefore, we decided that the Plan 
has to pay for physical therapy services provided from August 4, 2020, to August 13, 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 to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care services (99291) provided on June 21, 2020.
You asked the Plan to pay for the critical care services. You say that you would like reconsideration based on
the records submitted. The Plan denied your request. The Plan says the documentation does not support the
services billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of code 99291 is critical care, evaluation and management of the
critically ill or critically injured patient; first 30-74 minutes.
We find that CPT code 99291 is not supported in the record. Specifically, the documentation submitted does
not include the amount of time spent rendering the critical care services. Based on this information, we decided
that Medicare rules for coverage of the critical care services have not been met. Therefore, we decided that the
Plan does not have to pay for critical care services (99291) provided on June 21, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 18, 2019 by a non-network provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by a non-network provider without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The 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 medical services provided on December 18, 2019 by a non-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services provided on January 16, 2019.You asked the Plan to pay forthe laboratory services. You say that you would like the Plan to reconsider their denialof payment.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. In this case, theclaim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting.Therefore, we decided that the Plan does not have to pay forthe laboratory services providedon January 16, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on May 28, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 64721 is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 64721 is neuroplasty and/or transposition; median nerve at carpal tunnel. We find that CPT code 64721 is not supported in the medical record. Specifically, the primary surgeon's claim does not list the same billed code. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the surgical services rendered on May 28, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayments forskilled nursing facility (SNF) services provided from July 1, 2019, to August 19, 2019.You asked the Plan to reduce the copayments forthe SNF services. You say that you believe the enrollee had met her annual Maximum Out Of Pocket (MOOP) amount prior to these services, so these copayments should be waived.The Plan denied your request. The Plan says the MOOP had not been satisfied prior to these services.  The enrollee had a hospital claim in June of 2019 that originally applied an $1800 copayment (which would have meant that the MOOP was satisfied prior to the SNF services).  However, that hospital claim was reprocessed and the copayment was removed.  As a result, the MOOP had not been met as of the dates of these SNF services. The Plan took another look at the enrollee's claim history and did find that the MOOP calculation was off by $8.25,  so the copayment obligation has been reduced by that amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $0 copayment per day for days 1-20 and a $172 copayment per day for days 21-100 for skilled nursing facility services. Records show that the enrollee was in a SNF for a total of 46 days.  For the first 20 days, she was charged a $0 copayment per day in accordance with her contract.  For the remaining 26 days, a $172 copayment per day applied.  This totals $4,472.  However, as of the time of these services, therewas only $1,462.93 remaining before meeting the MOOP.  That is the amount being requested at this time. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan.Therefore, we decided that the Plan does not 
have to reduce the copayments forskilled nursing facility (SNF) services provided from July 1, 2019, to August 19, 2019
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections
You asked the Plan to pre-approve facet joint injections. You say that you are appealing with records. The Plan
denied your request. The Plan says the denial of authorization for this service is correct, because this service is
not medically necessary.
The Plan follows Medicare rules. Medicare rules say that facet joint interventions may be covered if certain
clinical criteria are 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 facet joint injections. Our reviewer says
that the enrollee does not meet the Medicare criteria for the requested facet joint injections. Our physician
reviewer found the documentation does not support that the enrollee has had at least two medically reasonable
and necessary diagnostic medial branch blocks (MBBs), with each one providing a minimum of 80% relief of
primary pain or at least 50% improvement in the ability to perform previously painful movement and activities
of daily living, or has had at least one medically reasonable and necessary therapeutic injection that provided at
least 50% pain relief for at least three months.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan
does not have to pre-approve facet joint injections
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the air ambulance services provided.

You asked the Plan to pay for the air ambulance services. 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 follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your medical condition is such that transportation by ground ambulance is not appropriate. 

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 the air ambulance services. Our reviewer says that the documentation does not support that the rendered services were medically reasonable or necessary. Our physician reviewer found the documentation appears to be a mode of transportation for end of life care. Due to the distance and the extreme discomfort of this enrollee with any other mode of transportation, Air Transport was felt to be the most humane to minimize suffering.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network
provider on April 15, 2020.
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 you by an out-of-network provider on April
15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an external insulin infusion pump.

You asked the Plan to pre-approve the requested services. You say that you have tried multiple avenues to control your blood sugar, with no success.The Plan denied your request. The Plan says coverage criteria have not been met.

The Plan must follow Medicare rules. Medicare rules say that infusion pumps are only covered under certain medical indications. 

We looked at the file and Medicare rules.The records provided show that your pancreas is functioning, and your C-peptide level is normal. Based on this information, we decided that Medicare rules for coverage have not been met.Therefore, we decided that the Plan does not have to pre-approve an external insulin infusion pump
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6545.
You asked the Plan to pre-approve the compression stockings. You say that you believe that these are needed
as ordered by your doctor. The Plan denied your request. The Plan says you do not have a venous stasis ulcer
for which these stockings can be covered.
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6545
are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that
compression bandages and gradient compression wraps are covered only when they are used as dressings over
a qualifying wound.
The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you
do not have a medical condition for which compression stockings can be covered or paid for by Medicare.
Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code
A6545.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided by an out of network (OON) provider.

You asked the Plan to pay for the medical services. You say that these services were provided in good faith to a nursing home resident.The Plan denied your request. The Plan says unauthorized, non-plan care is not covered.

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 medical services provided by an out of network (OON) provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea power seat elevation system (E2300).You asked the Plan to pre-approvea power seat elevation system. You say that this item is not medically necessary.The Plandenied your request. The Plan says this item is not a covered benefit.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is not a covered benefit of Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approvea power seat elevation system (E2300).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to you by an out-of-network provider
on March 9, 2020.
You asked the Plan to pay for the services. You say that you need the money reimbursed. The Plan denied your
request. The Plan says this provider 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 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 services provided to you by an out-of-network provider on March 9, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forinpatient post stabilization care provided on September 26, 2020, through September 27, 2020.You asked the Plan to pay forpost stabilization care. You say that the services were medically necessary.The Plan denied your request. The Plan says the enrollee's emergency medical condition stabilized by 7:40 am on 09/26/18and subsequent care was post stabilization care, not approved in compliance with the health plan's authorization procedures.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 post stabilization care. Our reviewer says that the service is not medically necessary. Our physician reviewer found all inpatient care provided after 7:40 am on 09/26/18 to 2:16 pm on 09/27/18 was not needed on an emergent basis. The enrollee was hemodynamically stable and appropriate for ambulance transport with monitoring to a Plan facility for continued observation/inpatient level of care services. The post-stabilization care services at the non-Plan facility were not medically necessary or reasonable. The review has determined that the treating physician did not document (in the physician notes, on a form, or in an order) that the patient was not stable for transfer on any dates of service.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of post stabilization care have not been met.Therefore, we decided that the Plan does not have to pay forinpatient post stabilization care provided on September 26, 2020, through September 27, 2020.