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

We decided that the Plan does not have to pre-approve additional in-network benefits for an out-of-network provider.You asked the Plan to pre-approve the in-network benefits. You say that you would like reconsideration because you have been seeing this provider for years and they come to the facility whereyou reside. The Plan denied your request. The Plan says there are in-network providers in the region with no network inadequacies seen.The Plan must follow Medicare rules. Medicare rules say that a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles and coinsurance). We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the in-network benefits have not been met. Specifically, the Health Plan contract discloses clear and accurate terms for all cost-sharing information. Therefore, we decided that the Plan does not have to pre-approve additional in-network benefits for an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (HCPCS S9328) services provided to the enrollee from November 25, 2019 to December 2, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says this is an invalid procedure code for this service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. We find that HCPCS code S9328 is not supported in the medical record. Specifically, this code has a status indicator of I according to the Medicare Physician's Fee Schedule. This indicates that the code is not valid for Medicare purposes. 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 home infusion therapy (HCPCS S9328) services provided to the enrollee from November 25, 2019 to December 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveendovenous ablation for enrollee.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that endovenous ablation is covered when specific 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has documented severe knee arthritis and a body mass index (BMI) of 52.4. There is no documentation that she is having lifestyle living symptoms specifically due to the venous reflux. There is no documentation of any effort at conservative treatments. There is no documentation of ulceration. Additionally, as the documentation does not describe severe symptoms that could be attributed to the varicose veins or provide evidence that she would significantly benefit from ablation of her bilateral greater saphenous and left short saphenous vein. The 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-approveendovenous ablation for enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for EGD's provided by an outpatient hospital
facility on March 26, 2019 and September 17, 2019.
You asked the Plan to waive the copayments for EGD's. You say that you were never made aware of 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 a $0
copayment for each outpatient hospital facility visit, a $200 copayment for observation and a $300 copayment
for all other outpatient services.
You received EGD's on March 26, 2019 and September 17, 2019. EGD's are considered outpatient surgical
procedures. Therefore, you are responsible to pay a $300 copayment per each EGD. The total amount you owe
is: $600.
You have been asked to pay the total copayment amount of $600 for EGD's. EGD's fall 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 copayments for EGD's provided by an outpatient hospital
facility on March 26, 2019 and September 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre Continuous Glucose Monitor (CGM).
You asked the Plan to pre-approve the Continuous Glucose Monitor. You say that the CGM is medically
necessary. The Plan denied your request. The Plan says rules for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they
are medically reasonable and necessary and replace a blood glucose monitor.
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 Continuous Glucose Monitor. Our
reviewer says that coverage criteria has not been met. Our physician reviewer found the enrollee does not
regular adjust insulin dosage. The enrollee checks blood glucose twice daily. The records do not support that a
continuous monitor is 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 the Continuous Glucose Monitor have not been met. Therefore, we decided that
the Plan does not have to pre-approve a Freestyle Libre Continuous Glucose Monitor (CGM).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve a pneumococcal vaccine.You asked the Plan to pre-approvethe vaccine. The Plan denied your request. The Plan says that the enrollee had this vaccine in 2018.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the vaccine. Our reviewer says that the requested vaccine is considered medically reasonable and necessary in this case. Our physician reviewer found that this enrollee demonstrates lack of sufficient protection against streptococcal pneumoniae given low antibody titers in November 2019 (+1/14 responsive only). Although there is documentation that she received the vaccination in 2018, it is unknown whether she had poor response or adequate response that waned over time given that her titers were not checked in 2018. Even so, it would be medically appropriate to re-vaccinate her and therefore attempt to provide her protection to this bacteria as well as be able to assess her antibody response by checking her post vaccination antibody titers.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 vaccine have been met.Therefore, we decided that the Plan has to pre-approvea pneumococcal vaccine.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 30, 2019 to
September 4, 2019 by an out of network (OON) provider.
You asked the Plan to pay for skilled nursing services. 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.
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 30, 2019
to September 4, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient lab work provided on October 8, 2019 by an out of network (OON) provider.
You asked the Plan to pay for outpatient lab work. You say that you would like this appeal reprocessed and approved for payment. The Plan denied your request. The Plan says the referring provider 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 for outpatient lab work provided on October 8, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visits provided on September 24, 2019 and November 19, 2019.
You asked the Plan to waive the copayment for the office visits. You say that the provider counsels you. You say that the copayments should be $20. The Plan denied your request. The Plan says the copayments applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for each Medicare-covered individual therapy session. You have been asked to pay a $40 copayment for each office visit. The total amount you owe is $80 ($40/visit x 2 visits = $80). The office visits fall within the "Outpatient Mental Health Care" 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 office visits provided on September 24, 2019 and November 19, 2019.
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 your wife called 911 because she had found you passed out. She believed the call was necessary because of your prior medical conditions. You say that the responders came and after evaluating you they found that your heart was fine and that you had passed out due to low blood sugar levels. They treated you with an IV and asked you if you wanted to go to the hospital. You say that you declined and were told there wouldn't be a charge anyway. You believe that the services were medically necessary and should be covered by the Plan. 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 April 1, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for podiatry services provided on November 1, 2019 by an out of network (OON) provider.
You asked the Plan to pay for podiatry services. You say that these services were medically necessary. The Plan denied your request. The Plan says these services are no considered a medical emergency. 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 for podiatry services provided on November 1, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says care can be received in a lower level of care.
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 records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a SNF level of care. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at a SNF. A less intensive, longer duration of therapy can allow for measurable gains to be attained within a reasonable period. 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a SNF admission and services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that the enrollee would benefit from physical therapy to become stronger. The Plan denied your request. The Plan says the enrollee is at her baseline, and has no pain.
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 services. Our physician reviewer found that from a nursing perspective, the enrollee had stable vital signs. There are no identifiable skilled nursing service needs. Regarding rehab services, the enrollee is at a standby to supervision assist level with functional mobility. Although there are identifiable skilled therapy service needs, the enrollee does not require skilled nursing or therapy services on a daily basis. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on July 17, 2019 by an out of network (OON) provider.
You asked the Plan to pay for an office visit. You say that you cannot afford this. You say that you would like this to be billed as an in-network office visit. 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 an office visit provided on July 17, 2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered to the enrollee on July 9, 2019.
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 21011 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 21011 is excision, tumor, soft tissue of face or scalp, subcutaneous; less than 2 cm. We find that CPT code 21011 is not supported in the medical record. Specifically, the documentation shows that excision of malignant melanoma in situ was performed and there is a more appropriate code for these services. 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 services rendered to the enrollee on July 9, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide coverage foradditional routine transportation.You asked the Plan to provide coverage foradditional routine transportation. You say that additional transportation is medically necessary.The Plan denied your request. The Plan says once this benefit is exhausted it cannot be extended.Medicare does not cover routine transportation. While plans may offer supplemental transportation benefits,they are not required to do so. Medicare does not provide exceptions to supplemental benefits. Therefore, we decided that the Plan does not have to provide coverage foradditional routine transportation.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay fora duplex scan provided on September 11, 2019 by an out of network (OON) provider.You asked the Plan to pay fora duplex scan. You say that youwould like this reprocessed and approved for payment.The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that this provider is now in-network but was out-of-network at the time of 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 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 fora duplex scan provided on September 11, 2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe endovenous ablation therapy (36475) provided on March 29, 2019.You asked the Plan to pay forthe endovenous ablation therapy (36475). You say that the provided endovenous ablation therapy was medically necessary.The Plan denied your request. The Plan says the enrollee did not meet criteria for the provided endovenous ablation therapy. 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 pay for the endovenous ablation therapy (36475). Our reviewer says that the enrollee did not meet criteria for the provided endovenous ablation therapy. Our physician reviewer found the documentation does not meet the coverage criteria and does not support the medical necessity of the treatments in question. The enrollee is seen on 3/29/2019. The enrollee complains of clumsy ambulation and swelling. It is noted the pain is worse on the right. Is not described that the enrollee is having functionally limiting pain in the distribution of the small saphenous veins. There is no documentation of anyeffort at conservative treatment. Recommendation on 3/29/2019 is to obtain an ultrasound in 1 week however the enrollee undergoes right small saphenous vein ablation on 3/29/2019 (same day). There is no documentation of significant symptoms on the left but on 4/11/2019 the enrollee undergoes left short saphenous vein ablation. On 4/8/2019 the enrollee undergoes a duplex that demonstrate closure of the right short saphenous vein with the recommendation for left greater saphenous vein ablation without medical record documentation of the enrollee's response to its short saphenous vein ablation. Duplex examination demonstrating reflux in the veins treated in absence of DVT are not included in the materials provided. Based on all the above, the requested procedure does not meet criteria.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 endovenous ablation therapy (36475) have not been met.Therefore, we decided that the Plan does not have to pay forthe endovenous ablation therapy (36475) provided on March 29, 2019.