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

We decided that the Plan does not have to pay for the ambulance services.You asked the Plan to pay for the ambulance services. You say that you were at a casino and you began to feel dizzy. An ambulance was called by security, and when it arrived the responders evaluated you and checked your vitals. You did not want to be treated or transported and since you were fine you went to your room. You say that you should not be held responsible because you did not ask for the ambulance to be called.The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on October 2, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lab services provided to the enrollee on August 19, 2019.You asked the Plan to pay forthe lab services. The Plan denied your request. The Plan says screening tests are not covered.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.The testing at issue in this appeal, the lab services, was requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes.Therefore, we decided that the Plan does not have to pay forthe lab services provided to the enrollee on August 19, 2019
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that you feel that the enrollee would benefit from this care.The Plandenied your request. The Plan says the criteria for the IRF level of care are not met.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked ourphysician 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 enrollee was admitted on 2/1 for COPD exacerbation, respiratory failure, and acute kidney injury. The patient is noted to be weaker than usual after a several-day hospital stay, and below her prior level of function. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the patient's medical status requires the intensity of an IRF stay with close physician or nursing supervision. The patient may benefit and participate in additional therapy of PT and OT,but the patient does not require this on an intensive rehabilitation facility therapy program level 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on August 23, 2019 by an out of network (OON) provider.You asked the Plan to pay foran office visit. 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 canrequire 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 foran office visit provided on August 23, 2019 by an out of network (OON) provider
Appeal type: Practitioner Services
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 September 23, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network deficiency 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 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 September 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for ophthalmological services provided on February 7, 2019.
You asked the Plan to pay for the ophthalmological services. The Plan denied your request. The Plan says he Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for ophthalmological services provided on February 7, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zilretta injection services.
You asked the Plan to pre-approve the Zilretta injection services. You say that the enrollee will have decreased
function in activities of daily living and an inability to continue exercise in order to maintain a healthy lifestyle,
without access to interventions like Zilretta. You say that the enrollee has tried physical therapy, cortisone
injections, oral nonsteroidal anti-inflammatory drugs, and topical lotions without the same relief that the
Zilretta has given him. You say that it is in the best interest of the patient and the insurance to allow him to
have continued coverage and access to Zilretta injections. The Plan denied your request. The Plan says the
safety and success of repeating Zilretta injection services have not been studied.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe
and effective and otherwise reasonable and 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 Zilretta injection services. Our
reviewer says that the criteria for coverage have not been met. Our physician reviewer found Zilretta is an
extended-release injectable suspension of Triamcinolone acetonide. Zilretta is for the injection of a single 32
mg dose (5mL) intra-articularly. The safety and efficacy of repeat administration has not been established. A
repeat injection of this drug is not considered 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 Zilretta injection services have not been met. Therefore, we decided that the
Plan does not have to pre-approve Zilretta injection services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 8, 2019 by an out of network (OON) provider.You asked the Plan to pay for physician visit. You say that you are appealing.The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and prior authorization was not obtained.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay for the medical services provided on August 8, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for assembly and operation of pump with oxygenator or heat exchanger provided September 13, 2019.
You asked the Plan to pay this claim. You say that this equipment was provided to the enrollee during an inpatient stay and should be covered. The Plan denied your request. The Plan says this claim cannot be paid separately based on Medicare guidelines for inpatient services. The Plan says that this claim should be submitted to the facility.
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. This equipment was used during and after a surgical procedure by the facility. Payment for this service would have been included under the facility claim. Payment to you for this service is the responsibility of the facility or hospital. Therefore, we decided that the Plan does not have to pay for assembly and operation of pump with oxygenator or heat exchanger provided on September 13, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for cerebral perfusion analysis (0042T) provided on September 29, 2019.
You asked the Plan to pay for cerebral perfusion analysis. You say that this was medically necessary. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. Medicare rules list CPT code 0042T as non-covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of cerebral perfusion analysis have not been met. Specifically, this procedure is not covered by Medicare. Therefore, we decided that the Plan does not have to pay for cerebral perfusion analysis (0042T) provided on September 29, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve clotrimazole solution.
You asked the Plan to pre-approve self-administered drugs. You say that the enrollee has been treated with this drug in the past and it works well. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve clotrimazole solution.
Benefits for self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sleep study described by procedure code 95810.You asked the Plan to pre-approve these services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 95810 is not covered.The Plan must follow Medicare rules. The rules say that, for edits with a modifier indicator of 0, the Column 2 code cannot be paid regardless of whether a modifier is used.The services at issue are a sleep study described by code 95810. The Plan has approved a sleep study under code 95811. Code 95810 is a column II code with a modifier indicator of 0 when billed with column I code 95811. Code 95810 cannot be approved with code 95811.Therefore, we decided that the Plan does not have to pre-approve a sleep study described by procedure code 95810.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids purchased on January 2, 2019.
You asked the Plan to pay for the hearing aids. You say that you should be reimbursed because you need
hearing aids. The Plan denied your request. The Plan says that no prior authorization was obtained for services
rendered by an out of network provider.
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 received from a participating provider.
We looked at the file and the Plan's rules. The file indicates you did not receive the hearing aids from a
participating provider. Based on this information, we decided that the Plan's rules for coverage of the hearing
aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids purchased
on January 2, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing rendered on August 7, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plandenied your request. The Plan says there is no valid physician order.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 forthe drug testing rendered on August 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the pain management services to be provided by an out of network 
You asked the Plan to pre-approve the pain management services. You say that the out-of-network services with the provider are medically necessary. The Plan denied your request. The Plan says there are plan providers that can provide the services at issue, and the plan has concerns about the safety of the treatment being provided by the provider
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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 has provided referral to the provider's Interventional Pain Service (IPS). The Enrollee has declined these services. We found no exception that would require the Plan to pre-approve service. Therefore, we decided that the Plan does not have to pre-approve the pain management services to be provided by an out of network
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on June 20, 2019.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plandid not pre-approve the servicesat 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 physician's services providedon June 20, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee on May 3, 2018.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was submitted after the timely filing limit.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service. The record shows that a claim for the services was not filed until July 15, 2019. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the services provided to the enrollee on May 3, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on July 18, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says nonemergent,
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 physician's services provided on July 18, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria for continued SNF care has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nursing facility care provided on August 7, 2019 by an out of network (OON) provider.You asked the Plan to pay for nursing facility care. You say that our provider cannot deny any medical services that were essential for patient health treatmentThe Plan denied your request. The Plan says the nursing facility is out-of-network. The Plan says that no prior authorization was obtained.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay fornursing facility care provided on August 7, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean immediate upper denture (D5130) and an immediate lower denture (D5140).You asked the Plan to pre-approvethe dental services. You say that you were advised by your dentist that you do not need the partial dentures, but the full dentures instead. You also say that you were advised to contact the Plan for an adjustment.The Plan denied your request. The Plan says dentures are covered once every 5 years. The Plan also says that the frequency limit has been reached.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 and dentures are a covered service, the frequency limit has been reached. The record shows that the Plan previously paid for partial dentures on that you received February 14, 2019.Therefore, we decided that the Plan does not have to pre-approvean immediate upper denture (D5130) and an immediate lower denture (D5140).