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

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.

You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee is receiving adequate and necessary intensive rehabilitation in the Inpatient Rehabilitation Facility.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF services. 

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 skilled nursing facility (SNF) services for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided by an out-of-network provider on April 3, 2020.

You asked the Plan to pay for the laboratory services. You say that you provided medically necessary services in good faith and are seeking reconsideration. The Plan denied your request. The Plan says in-network providers were available to perform the services.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for laboratory services provided by an out-of-network provider on April 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the ophthalmology consultation to be provided by an
OON provider.

You asked the Plan to pre-approve the ophthalmology consultation. You say that you do not feel comfortable
seeing the network provider since it is a very extensive surgery and the specialist recommended is not nearly
experienced with it. The Plan denied your request. The Plan says enrollee's must receive their medical services
from an in-network provider with the exception being urgent or emergent services. Non-emergent services with
non-contracted providers require prior authorization before services being rendered.

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
the ophthalmology consultation to be provided by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that you can safely receive the services you need in other settings.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for falls, hypotension and hyponatremia. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary.
The Plan denied your request. The Plan says that your illness is not complex enough to require daily physician
management and you do not require specialized nursing services that are only available in an LTACH.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. You are
receiving appropriate care at the present acute care hospital. You do not require services at the LTACH that are
not available at the acute care hospital where you are currently receiving care. Our physician reviewer found
that your condition does not meet Medicare criteria for LTACH services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for office visits provided by an out of network (OON) provider.

You asked the Plan to pay for the office visit. You say that the only in-network specialist is located too far away and travel to Dallas is not feasible. The Plan denied your request. The Plan says the 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 Pain Management Specialists 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 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for office visit services (CPT 99203) provided to the enrollee on October 5, 2020.
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 Medicare rules say that CMS does not separately pay any provider or supplier other than the facility for services furnished to the beneficiary in preparation for, or for a procedure or surgery.
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 99203 is "office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low level of medical decision making." We asked our coding 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our coding reviewer found this service is not separately reported, and would be the responsibility of the facility to furnish all necessary services/supplies or arrangements are made between the facility and outside vendor. We looked at this coder's review, the file, and Medicare rules. 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 office visit services (CPT 99203) provided to the enrollee on October 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Floweramnioflo injections.
You asked the Plan to pre-approve Floweramnioflo, 0.1 cc (Q4177). You say that you need the injections for neck pain. The Plan denied your request. The Plan says this procedure is considered investigational, and not reasonable and necessary.
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 Floweramnioflo, 0.1 cc (Q4177). Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is an experimental/ investigational medication for neck pain. It is not medically reasonable or 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 Floweramnioflo, 0.1 cc (Q4177) have not been met. Therefore, we decided that the Plan does not have to pre-approve Floweramnioflo injections.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital services provided from February 4, 2018, through February 5, 2018.

You asked the Plan to pay for the hospital services. The Plan denied your request. The Plan says claims must be filed to the appropriate Medicare claims processing contractor no later than 12 months, or 1 calendar year, after the date the services were furnished.

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 hospital services was not filed until January 24, 2020. 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 hospital services provided from February 4, 2018, through February 5, 2018.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room service with current procedural terminology (CPT) code 99285 provided on October 21, 2020.
You asked the Plan to pay for CPT code 99285. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says CPT code 99285 was previously paid on a separate claim for the same enrollee, on the same date of service, and from the same provider.
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must confirm that Medicare coverage criteria have been met.
We looked at the file, the Plan's contract and Medicare rules. The file shows that the Plan had previously paid for CPT code 99285 on a different claim with the same enrollee, date of service, and provider. Therefore, we decided that the Plan does not have to pay for the emergency room service with current procedural terminology (CPT) code 99285 provided on October 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Quantum Q6 Edge 2.0 power wheelchair for the enrollee.

You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied your request. The Plan says this is only covered for use in the home.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home. 

Records show that the wheelchair is being requested for use in a SNF or hospital. Therefore, we decided that the Plan does not have to pre-approve the Quantum Q6 Edge 2.0 power wheelchair for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Testosterone Gel.
You asked the Plan to pre-approve Testosterone Gel. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested item is not a covered benefit.
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 Testosterone Gel.
Benefits for Testosterone Gel 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve nutrition therapy (97802).
You asked the Plan to pre-approve nutrition therapy. You say that you need this for your heart condition and bowel obstruction. The Plan denied your request. The Plan says this is not covered for your condition.
The Plan must follow Medicare rules. Medicare rules say that medical nutrition therapy services (MNT) is covered for certain beneficiaries who have diabetes or a renal disease. We looked at the file and Medicare rules. The record does not show that you have diabetes or a renal disease. Based on this information, we decided that Medicare rules for coverage of nutrition therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve nutrition therapy (97802).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a core buildup, including any pins when required
(D2950) and pulp cap (D3120).
You asked the Plan to pre-approve the core buildup and pulp cap. You say that you would like these services to
be approved for coverage. The Plan denied your request. The Plan says these services are not covered under the
enrollee's benefit plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a
core buildup, including any pins when required (D2950) and pulp cap (D3120).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care provided on June 30, 2020.
You asked the Plan to waive the copayment for emergency care. You say that you contracted a bug during the visit and had to be admitted to the hospital a few days later due to it. 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 $90 copayment for emergency care. You have been asked to pay a $90 copayment for emergency care. Emergency care falls within the emergency 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 emergency care provided on June 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement for the male vacuum erection system (L7900) provided on December 2, 2020.
You asked the Plan to issue reimbursement for this item. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says this item is not a covered benefit under your contractual policy or by Medicare.
The Plan must follow Medicare rules. The rules say that a vacuum erection system is statutorily non-covered.
The item at issue in this appeal is not covered by Medicare. Therefore, we decided that the Plan does not have to issue reimbursement for the male vacuum erection system (L7900) provided on December 2, 2020.
Your complaint about being advised by a Plan representative that this item was authorized is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ultraviolet light therapy for the enrollee.
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your request. The Plan says the records do not indicate any psoriasis.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the therapy. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a history of mycosis fungoides. The review indicates that the enrollee does not have generalized intractable psoriasis that would indicate this request as medically necessary and reasonable. 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 therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve ultraviolet light therapy for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refraction you had on November 30, 2020.

You asked the Plan to pay for the refraction. The Plan denied your request. The Plan says this is not a covered benefit.

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 services when provided during a routine exam.

We looked at the file and the Plan's rules. The requested eye refraction was not provided during a routine eye exam. Based on this information, we decided that the Plan's rules for coverage of the refraction have not been met. Therefore, we decided that the Plan does not have to pay for the eye refraction you had on November 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says this 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 the device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device is experimental. More research is needed to show safety and efficacy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found you were admitted for a stroke. Your medical problems are stable. There are no complex nursing or rehabilitation needs. The documentation does not support that you require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not support that you require an intensive rehabilitation therapy program. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.