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

We decided that the Plan does not have to pay forthe medical services provided to you by an out-of-network provider on February 25, 2020.You asked the Plan to pay forthe services. The Plandenied 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 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 servicesat 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 forthe medical services provided to youby an out-of-network provider on February 25, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home visit (99348) provided on July 12, 2019.You asked the Plan to pay forthe home visit. You say that you would like reconsideration because the services rendered were medically necessary.The Plan denied your request. The Plan says the billed code does not appropriately reflect the services provided.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 ofcode 99348 is home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused interval history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Typically, 25 minutes are spent face-to-face with the patient and/or family. We find that CPT code 99348 is not supported in the record. Specifically, the record does not indicate that the physician was present in the beneficiary's home. Based on this information, we decided that Medicare rules for coverage of the home visit have not been met.Therefore, we decided that the Plan does not have to pay forthe home visit (99348) provided on July 12, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on February 11, 2020 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 approved for
payment. The Plan denied your request. The Plan says prior authorization was not obtained by a participating
provider. The Plan says that the referring provider is also out-of-network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the 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 February 11, 2020 by an out
of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the enrollee needs prolonged hospitalization for attempted weaning from high-flow oxygen.The Plan denied your request. The Plan says the enrollee is receiving appropriate care in the acute care hospital.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 casefile and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our physician reviewer found that the enrollee was admitted to the acute care hospital with respiratory failure due to Covid-19 pneumonia. LTACHs are certified as acute care hospitals, and in general, do not provide clinical services that are materially different than those of short term acute care hospitals. The enrollee is receiving acute hospital care, and acute care services have not been denied.The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where she is currently receiving care.The clinical assessment does not support that the enrollee is reasonably expected to benefit from, and improve with, LTACH services.Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time.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-approvelong term acute care hospital (LTACH) services
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for an EKG provided on June 5, 2020 by an out of network
(OON) provider.
You asked the Plan to pay for an EKG. You say that you were referred. You say that you would like this claim
reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization was
not obtained by an in-network provider. The Plan says that the referring provider is out-of-network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the 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 EKG provided on June 5, 2020 by an out of
network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on June 12, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, 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 physician's services. 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 June 12, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay forout of network outpatient mental health care provided from March 18, 2020, to May 13, 2020.You asked the Plan to pay forthis service. You say that the provider told you they take your type of insurance.  The Plan denied your request. The Plan says you did not have prior authorization 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 mustpay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The contract also stated outpatient mental health care requires prior authorization. The 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 forout of network outpatient mental health care provided from March 18, 2020, to May 13, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda for the enrollee.

You asked the Plan to pre-approve the drug. You say that this is medically necessary.The Plan denied your request. The Plan says off-label use is medically accepted when there is evidence in one or more of the compendia or in the medical literature that it works for the disease in question.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 

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 drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found Keytruda is not FDA approved for the requested use. The drug is no supported in any of the CMS approved compendia for this use. The use is not listed as not indicated, not recommended, or not supported in any of the compendia.

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 drug have not been met.Therefore, we decided that the Plan does not have to pre-approve Keytruda for the enrollee
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe eye refraction services (92015) provided July 9, 2020.You asked the Plan to pay forthe refraction services. You say that this visit was in conjunction with being diagnosed with having a stroke which affected your vision and also memory.The Plan denied your request. The Plan says the refraction was performed as part of a medical exam and is therefore not covered per the plan benefits.Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these serviceswhen rendered by a participating provider and performed as a routine exam..We looked at the file and the Plan's rules. Eye refraction services are covered only when provided as a part of a 
routine vision exam. Based on this information, we decided that the Plan's rules for coverage of the refraction services have not been met.Therefore, we decided that the Plan does not have to pay forthe eye refraction services (92015) provided July 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Cardio MEMS system for the enrollee.

You asked the Plan to pre-approve a Cardio MEMS system. You say that this is medically necessary.The Plan denied your request. The Plan says that this service is considered experimental and investigational.

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 a Cardio MEMS system. Our reviewer says that a Cardio MEMS system is not considered medically reasonable and necessary in this case. In this circumstance therapy change based on data obtained from a Cardio MEM device has been demonstrated in only one randomized prospective trial to help reduce hospital readmission compared to standard medical therapy. Moreover, concerns have been raised about potential bias in this trial calling into question the results. Therefore, the efficacy of the Cardio MEMS device is uncertain at this time according to leading authorities and not recommended in current guidelines for the treatment of heart failure. The device is considered experimental or investigational. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of a Cardio MEMS system.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Cardio MEMS system have not been met.Therefore, we decided that the Plan does not have to pre-approve a Cardio MEMS system for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for prescription lenses on existing frames provided on February
26, 2020 and March 11, 2020.
You asked the Plan to pay for prescription lenses. You say that the service should be covered. The Plan denied
your request. The Plan says you exceeded the allowed amount for this benefit and are responsible for the
difference in cost.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan covers $300 for the purchase and fitting of eyeglasses and pair of lens or contact lenses at a
network optical provider.
We looked at the file and the Plan's rules. You have exceeded your maximum allowed for this benefit. Based
on this information, we decided that the Plan's rules for coverage of prescription lenses have not been met.
Therefore, we decided that the Plan does not have to pay for prescription lenses on existing frames provided on
February 26, 2020 and March 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forpsychotherapy provided on August 4, 2019 by an out of network (OON) provider.You asked the Plan to pay forpsychotherapy. You say that this was routine care; therefore, no authorization is needed.The Plan denied your request. The Plan says prior authorization was not obtained by the nursing facility or 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 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 forpsychotherapy provided on August 4, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete maxillary denture and complete mandibular
denture provided on June 24, 2020.
You asked the Plan to pay for the complete maxillary denture and complete mandibular denture. You say that
you were told by the Plan that dentures are covered. The Plan denied your request. The Plan says there is no
coverage for dentures. The Plan also says that your phone calls were reviewed, and you were advised that
dentures are not part of your covered benefits.
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
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
complete maxillary denture and complete mandibular denture provided on June 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe cervical collar provided on February 27, 2020.You asked the Plan to pay forthe cervical collar (L0120). You say that the Plan should pay this claim.The Plan denied your request. The Plan says there is no valid physician order orproof of delivery.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid physician order for the supplies provided in this case.The record shows that the Plan made several attempts to obtain the necessary documentation without success.Therefore, we decided that the Plan does not have to pay forthe cervical collar provided on February 27, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF).You asked the Plan to pre-approveadmission to a SNF. You say that the requested admission to a SNF is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission.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 admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse required to safely and effectively provide medically necessary and reasonable treatment in a SNF.  The enrollee does not have complex wound care, IV medications, new enteral feedings, nebulizers or other ongoing SNF level SN need. The enrollee is medically stable. The enrollee's functional level does not require skilled therapy services We decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF).You asked the Plan to pre-approveadmission to a SNF. You say that the requested admission to a SNF is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission.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 admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse required to safely and effectively provide medically necessary and reasonable treatment in a SNF.  The enrollee does not have complex wound care, IV medications, new enteral feedings, nebulizers or other ongoing SNF level SN need. The enrollee is medically stable. The enrollee's functional level does not require skilled therapy services
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department service provided on February 1, 2020.
You asked the Plan to pay for the emergency department service. You say that the Plan should pay this claim. The Plan denied your request. The Plan says this claim cannot be paid as submitted with F07.81 as the primary and first listed diagnosis code.
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 ICD-10-CM Diagnosis Codebook says code category F07 is Personality and behavioral disorders due to known physiological condition. Code first any associated: the underlying physiological condition. We find that this claim did not include the appropriate primary diagnosis code. Based on this information, we decided that Medicare rules for coverage of the emergency department have not been met. Therefore, we decided that the Plan does not have to pay for the emergency department service provided on February 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided  that  the  Plan  does not  have to waive  the deductible  forthe office  visit  provided  byanout-of-network  provider  on July  1, 2020.You asked the  Plan to waive  the deductible  forthe office  visit.  You  say that you  were told  there  was no charge for  the televisit  because  of the pandemic.  You say  that  your  balance  should  be zero.The  Plan  denied  your request.  The  Plan  says the  deductible  applied  correctly.The  rules  say a plan  must  disclose  to its  enrollees  in  clear,  accurate  terms  all  cost sharing  information.  Your contract  with  the  Plan  says  that  your  combined  deductible  is $500. This  is  the amount  you  have  to pay out-of-pocket before  we will  pay our  share for  your  covered  medical  services.  Until  you  have  paid  the  combined deductible  amount,  you  must  pay the  full  cost for most  of  your  covered  services. The  item  or service  you  asked the  Plan  to waive  the  deductible  for  falls  within  the "Physician/Practitioner services,  including  doctor's office  visits"  benefit  category.  The  Plan  has followed  Medicare  rules  by clearly disclosing  in  the  contract  that  your  $500 deductible applies  to office  visits.  This  cost sharing  is  a contractual obligation  that  had not been  met  at the  time  the  office  visit  was received  on July  1, 2020.The  Plan  says  that  only  out-of-pocket  costs for in-network  primary  care visits,  in-network  outpatient  behavioral health  visits  and in-network  telehealth  visits  are being  eliminated. Therefore,  we decided  that  the Plan  does not have to waive  the deductible forthe office  visit  provided  by an out-of-network  provider  on July  1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional intraoral periapical x-ray provided on July 22,
2020.

You asked the Plan to pay for the additional intraoral periapical x-ray. You say that you were not advised that
each dentist within any particular dentist office is accepted independently by the Plan. The Plan denied your
request. The Plan says benefits for this service have been satisfied and the frequency limitation has been
exceeded.

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, intraoral x-rays are limited to one
procedure per calendar year. The record shows that you received two additional intraoral periapical x-rays on
July 22, 2020, one of which was covered by the Plan, and your intraoral x-rays benefit has been exhausted.
Therefore, we decided that the Plan does not have to pay for the additional intraoral periapical x-ray provided
on July 22, 2020.