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

We decided that the Plan does not have to pay for an outpatient clinic visit, and diagnostic tests provided on
October 16, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for an outpatient clinic visit and diagnostic tests. You say that you would like this
claim reprocessed and paid due to medical necessity. The Plan denied your request. The Plan says prior
authorization was not obtained by the member's primary care physician.
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 had network providers
available who could have provided 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 an outpatient clinic visit, and diagnostic tests
provided on October 16, 2020 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a rear basket (K0108).

You asked the Plan to pre-approve the basket. You say that this is medically necessary. The Plan denied your request. The Plan says there is no medical or in-home need for this item.

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 available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a rear basket (K0108).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on March 1, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says the referring provider is out-of-network. The Plan says that the member's primary care physician did not refer 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 care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided 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 lab work provided on March 1, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the semi-electric hospital bed (E0260).

You asked the Plan to pre-approve the hospital bed. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says the records do not support that the enrollee meets the criteria for the requested semi electric hospital bed.

The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient:

1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or

2. Requires attachments which can only be attached to a hospital bed; AND 

3. Requires frequent changes in body position and/or has an immediate need for a change in body position.

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 hospital bed. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not clearly reveal that the enrollee's condition has failed positioning of the bed in ways not feasible in an ordinary bed or why positioning of the bed in other ways is not feasible. The documentation does not support a need for frequent or an immediate change in body position or special attachments that cannot be fixed on an ordinary bed. The request for a semi-electric hospital bed is not medically necessary for this enrollee.

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 hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve the semi-electric hospital bed (E0260).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an entrance ramp (E1399).
You asked the Plan to pre-approve a ramp. You say that the enrollee needs a ramp to get out of her house to post-operative medical appointments. Since there are steps at the exit of her home and the process to go down the stairs is difficult, so the use of the ramp is necessary. The Plan denied your request. The Plan says this item is not covered under the plan benefits under any normal circumstances.
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 available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve an entrance ramp (E1399).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy (PT) treatment (97110).
You asked the Plan to pre-approve physical therapy. You say that you are asking the Plan reinstate and continue additional physical therapy treatments to address the continue care you need to get well. The Plan denied your request. The Plan says the request for 16 physical therapy visits does not meet medical necessity criteria.
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 physical therapy. 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 the additional requested therapy is not generally accepted as specific
and effective therapy for the patient's condition beyond what was approved by the health plan. The enrollee has
had prior therapy and 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 by or under the supervision of a therapist. The enrollee has been instructed in a home
exercise program. The requested services are not part of a maintenance program, are the specialized skill,
knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to
maintain the patient'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 physical therapy have not been met. Therefore, we decided that the Plan does
not have to pre-approve physical therapy (PT) treatment (97110).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy rendered on February 5, 2021 to February 11, 2021.
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 are not covered.
The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies. We looked at the file and Medicare and the Plan's rules. The file shows that home infusion therapy services were rendered. Based on this information, we decided that Medicare and the Plan's rules for coverage of these
services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy rendered on February 5, 2021 to February 11, 2021.
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 enrollee needs admission to an IRF. The Plan denied your request. The Plan says criteria for admission to the IRF setting have 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 in the Medicare rules section. 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 that 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. Medical conditions are stable. There are no complex nursing or rehabilitation needs.
The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. 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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee and billed under
codes 90785 and 90832 for date of service October 15, 2020.
You asked the Plan to pay this claim. You say that these services should be paid by the Plan. The Plan denied
your request. The Plan says procedure code 90785 is listed as an Add-on code to for procedure code 90832 and
is not eligible for payment if the primary code is not paid. In addition the Plan states that Medicare payment for
clinical psychologist's services is limited to treatment by practitioners with a Psychology Doctoral degree,
Licensed or certified in the State, with patient consent, and consult with the attending or primary care
physician, There was no documentation of one or more of the criteria in the medical records provided.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate codes and when necessary provide additional records to
support the services billed.
In this case, this claim cannot be paid as billed due to insufficient medical record documentation and the
inappropriate billing of an add on code. Medicare rules for coverage of this claim have not been met.
Therefore, we decided that the Plan does not have to pay physician services provided to the enrollee and billed
under codes 90785 and 90832 for date of service October 15, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continued inpatient stay.
You asked the Plan to pre-approve the continued inpatient stay. You say that the in-network hospital is 1 hour away. You also say that you cannot go home if your emergency condition is not stabilized because your insurance does not want to pay for out-of-network inpatient hospital care. The Plan denied your request. The Plan says you are medically stable for transfer to an in-network hospital.
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 pre-approve the continued inpatient stay. Our reviewer says that the continued inpatient stay is not medically reasonable and necessary. Our physician reviewer found the records did not clearly state that you were not stable at any point in time. Our reviewer also found that based on the documentation provided, it appears that you were stable for transfer on August 17, 2021 as you were hemodynamically stable without complex needs and would have tolerated transfer. 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 continued inpatient stay have not been met. Therefore, we decided that the Plan does not have to pre-approve a continued inpatient stay.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the placement of a breast localization
device provided on March 22, 2021.
You asked the Plan to waive the copayment for the placement of a breast localization device. You say that you
were told that you would only owe a $40 copayment. The Plan denied your request. The Plan says the claims
were processed correctly and you are being charged the correct 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). Your contract with the Plan clearly says that you must pay a $350
copayment for outpatient surgery, including services provided at hospital outpatient facilities.
You received the placement of a breast localization device on March 22, 2021, at an outpatient hospital facility.
The placement of a breast localization device is considered an outpatient surgical procedure. Therefore, you are
responsible to pay the $350 copayment.
You have been asked to pay a $350 copayment for the placement of a breast localization device. The placement
of a breast localization device falls within the outpatient surgery, including services provided at hospital
outpatient facilities and ambulatory surgical centers 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 placement of a breast localization device provided on March 22, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the present setting where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided from January 6, 2021, to March 3, 2021.
You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that you cannot afford the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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). Your contract with the Plan clearly says that you must pay 20% coinsurance for Medicare Part B prescription drugs. You received Medicare Part B drugs on January 6, 2021. The total allowed amount is $3,507.43 and 20% of that is $701.49.
You received Medicare Part B drugs on January 29, 2021. The total allowed amount is $1,219.00 and 20% of that is $243.80. You received Medicare Part B drugs on February 3, 2021. The total allowed amount is $3,498.98 and 20% of that is $699.80. You received Medicare Part B drugs on March 3, 2021. The total allowed amount is $3,498.40 and 20% of that is $699.68. The total amount you owe is: $2,344.77. You have been asked to pay the total coinsurance amount of $2,344.77 for Medicare Part B drugs. Medicare Part B drugs fall within the Medicare Part B prescription drugs 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 coinsurance for Medicare Part B drugs provided from January 6, 2021, to March 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (99291 and 12013) provided on August 30, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the MUE has been exceeded.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. In this case, the MUE for CPT codes 99291 and 12013 is 1. The MAI value for this code is 2. You billed 2 units of each code, exceeding the MUE. 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 (99291 and 12013) provided on August 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and the periapical x-ray (D0220) provided on April 22, 2021.
You asked the Plan to pay for the dental services. You say that the basic x-rays and basic oral exam should be covered. The Plan denied your request. The Plan says limited oral evaluation is not listed as a covered service. The Plan says that periapical x-ray is not listed as a covered service either. The Plan also says you are responsible for the full cost of the services that are not covered by the 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, the limited oral evaluation and periapical x-ray are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) and the periapical x-ray (D0220) provided on April 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the observation services provided on February 2, 2021 to
February 3, 2021 by a non-contracted 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-contracted 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 had network providers
available who could have provided 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 observation services provided on February 2,
2021 to February 3, 2021 by a non-contracted provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says experimental and investigational procedures are not covered by Medicare.
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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental. More research is needed to show safety and efficacy of the device. 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.