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

We decided that the Plan does not have to pre-approve urology services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the OON services. You say that you have been seeing the provider for many years. The Plan denied your request. The Plan says there are network providers available for your care.
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 urology services at issue in this appeal. We found no exception that would require the Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve urology services to be provided by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for air ambulance services provided on November 10, 2019.You asked the Plan to pay forthe air ambulance services. You say that the flight was medically necessary and emergent.The Plan denied your request. The Plan says the enrollee was stable and did not require air ambulance transportation.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 service was not medically necessary. Our physician reviewer found based on the documentation provided that the health plan's denial should be upheld.  The enrollee had been experiencing pre-syncopal episodes.  The enrollee was still awaiting further evaluation following a recent abnormal Holter monitor test, when the enrollee presented to an emergency department with yet another presyncopal episode. In the emergency department the enrollee had stable vital signs and a normal sinus rhythm.  Upon review of the Holter monitor test, the decision was made to expedite the referral for additional evaluation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed.
You asked the Plan to pre-approve the requested bed. You say that you need to be able to get out of bed independent of anyone else helping you. The Plan denied your request. The Plan says a total electric hospital bed is not covered.
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Tdap vaccine provided on November 21, 2019.
You asked the Plan to pre-approve the Tdap vaccine. You say that you doctor suggested you receive the vaccine in dispute. The Plan denied your request. The Plan says the vaccine in dispute is not a covered benefit.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Tdap vaccine. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the Tdap vaccine. Therefore, we decided that the Plan does not have to pre-approve a Tdap vaccine provided on November 21, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 2D oral or facial photographic imaging (D0350 x 4) provided on October 1, 2019.
You asked the Plan to pay for the 4 2D oral or facial photographic images. You say that the provider Dental advised which provider's office the enrollee should go to for the services. You say that the enrollee was then assigned to an out of network provider. You say you were not advised that the dentist that provided the services was out of network. You also say that the enrollee is disabled, not working, and cannot pay for the dental services. The Plan denied your request. The Plan says 2D oral or facial photographic imaging is not listed as a covered service.
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 4 2D oral or facial photographic images are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 2D oral or facial photographic imaging (D0350 x 4) provided on October 1, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0482 provided on November 13, 2019.
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 G0482 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 drug class(es), including metabolite(s) if performed. We find that CPT code G0482 is not supported in the medical record. Specifically, the documentation submitted did not include a physician order/lab requisition or medical records stating exactly what tests are to be performed. The submitted laboratory requisition form indicates that oral panel was requested. The submitted documentation did not itemize what tests are included in this panel
. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded G0482 provided on November 13, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 23, 2019 by an out of network provider.
You asked the Plan to pay for the medical services. You say that the service was medically necessary. The Plan denied your request. The Plan says prior authorization was not requested.
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 July 23, 2019 by an out of network provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for needle electromyography (95870) provided on March 11, 2019.
You asked the Plan to pay for needle electromyography. You say that that this was billed correctly. The Plan denied your request. The Plan says this code is not supported in the documentation.
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 95870 is needle electromyography; limited study of muscles in 1 extremity or non-limb (axial) muscles (unilateral or bilateral), other than thoracic paraspinal, cranial nerve supplied muscles, or sphincters. 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 needle electromyography. Our reviewer says that this code is not supported. Our physician reviewer found needle electromyography; limited study of muscles in 1 extremity or non-limb (axial) muscles (unilateral or bilateral), other than thoracic paraspinal, cranial nerve supplied muscles, or sphincters is not documented in the report submitted. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of needle electromyography have not been met. Therefore, we decided that the Plan does not have to pay for needle electromyography (95870) provided on March 11, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 assay provided on November 27, 2019.You asked the Plan to pay for the Guardant360 assay. 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 a covered benefit.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.TheGuardant360 assay at issue in this appeal, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes.Therefore, we decided that the Plan does not have to pay for the Guardant360 assay provided on November 27, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided December 31, 2019 to January 2, 2020.
You asked the Plan to pay for acute inpatient hospital care. You say that the services were medically necessary. The Plan denied your request. The Plan says that coverage criteria was not met.
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 record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier 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 December 31, 2019 to January 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve osseous surgery.
You asked the Plan to pre-approve the osseous surgery. You say that you were not aware that the periodontics was not contracted. You also say that the Dental Provider was the one who referred you to periodontics. The Plan denied your request. The Plan says the provider requested for these services is not in the Dental network. The Plan also says that you must use network providers to get covered services.
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 requested items or services are not covered when they are received by an out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve osseous surgery.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to chemotherapy treatment with an out-of-network provider.
You asked the Plan to pre-approve the referral. You say that you would like your treatment in the state, as you have family matters to attend to in the state. The Plan denied your request. The Plan says the services are available in-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 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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral to chemotherapy treatment with an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory work provided on February 24, 2020.
You asked the Plan to waive the copayment for the laboratory work. You say that you are not supposed to have a copayment on laboratory work. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $20 copayment per day, per provider, for in-network Medicare-covered laboratory services. You have been asked to pay a $20 copayment for the laboratory work. The laboratory work falls within the "Outpatient diagnostic tests and therapeutic services and supplies" 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 laboratory work provided on February 24, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from January 1, 2020 to January 22, 2020.
You asked the Plan to pay for home health services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the type of bill code 323 used in this claim is invalid for pricing Non-Pat Home Health claims.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the
submitted claim includes an invalid type of bill code for home health services. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from January 1, 2020 to January 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown (D2740) provided on September 30, 2019.
You asked the Plan to pay for the dental service. You say that you have been seeing this dentist for at least 8
years. You say that you have a medical condition and do not want to change dentists. You also say that you did
not realize your dental plan was so limited. The Plan denied your request. The Plan says crowns are not a
covered service. The Plan says that services received from an out of network provider are not covered. The
Plan also says that the dentist in this case is out of network.
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 crown is not among those covered
under this benefit. Therefore, we decided that the Plan does not have to pay for the crown (D2740) provided on
September 30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a replacement manual wheelchair with accessories.
You asked the Plan to pre-approve a manual wheelchair and accessories. You say that the enrollee's wheelchair is broken and unsafe. The Plan denied your request. The Plan says there is no estimate on repairing or modifying the enrollee's current wheelchair.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The file shows that the enrollee has a manual wheelchair. There is no repair estimate. Therefore, we decided that the Plan does not have to pre-approve a replacement manual wheelchair with accessories.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, bitewings, and prophylaxis
provided on October 8, 2019.
You asked the Plan to pay for the periodic oral evaluation, bitewings, and prophylaxis. You say that you went
to the Plan's provider search website and saw that this provider was the plans Dentist. You also say that you were
led to believe these services were insurance covered procedures. The Plan denied your request. The Plan says
these services are not covered benefits when rendered by a dentist who does not participate in the Plan's
program. The Plan also says that this provider was not on a list of providers participating in your Plan network.
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 requested items or services are not
covered when they are received out-of-network. Therefore, we decided that the Plan does not have to pay for
the periodic oral evaluation, bitewings, and prophylaxis provided on October 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for wound care provided on May 29, 2019 by an out of network (OON) provider.
You asked the Plan to pay for wound care. You say that these services are provided in good faith that these services would be paid for. The Plan denied your request. The Plan says 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 for wound care provided on May 29, 2019 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued Skilled Nursing Facility (SNF) care after June 4, 2020.You asked the Plan to pre-approve SNF care. You say that walking, endurance, and pain are still a concern for you.The Plan denied your request. The Plan says the denial of authorization for continued SNF care after June 4, 2020 is correct.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 have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a Skilled Nursing Facility (SNF) 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 continued Skilled Nursing Facility (SNF) care after June 4, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient psychiatric services starting June 1, 2020.You asked the Plan to pre-approve these services. You say that the services are medically necessary.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records show that you were admitted to the hospital on May 20, 2020 with recurrent major depressive disorder and major neurocognitive disorder with behavioral disturbance. You do not have suicidal or homicidal ideation. You do not have any delusions or auditory or visual hallucinations. You are not showing dangerousness to yourself or others and are compliant with treatment. It does not appear that active treatment is taking place. The continued services are therefore not reasonable or 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approve continued inpatient psychiatric services starting June 1, 2020.