Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) and a knee orthosis with
suspension sleeve (L1833, L2397) provided to the enrollee on August 19, 2019.
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your
request. The Plan says the documentation does not support that services are necessary for treatment of the
enrollee's condition.
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 shows that the Plan made several attempts to obtain the physician order and proof of delivery
documentation for the items at issue in this appeal. The record does not contain a valid physician order and
proof of delivery for the supplies provided in this case. Therefore, we decided that the Plan does not have to
pay for a lumbar-sacral orthosis (L0650) and a knee orthosis with suspension sleeve (L1833, L2397) provided
to the enrollee on August 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for out-of-network services (73030, J3301,
99203, 20610) provided from December 3, 2019 to December 10, 2019.
You asked the Plan to waive the deductible for out-of-network services. You say that you were told this
provider accepted your insurance. The Plan denied your request. The Plan says these services processed
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 there is a $1000 deductible for most out-of-network services.
The services you asked the Plan to waive the deductible for are out-of-network services. The Plan has followed
Medicare rules by clearly disclosing in the contract that there is a $1000 deductible for most out-of-network
services. This cost sharing is a contractual obligation that had not been met at the time out-of-network services
was received on December 3, 2019 to December 10, 2019. Therefore, we decided that the Plan does not have to
waive the deductible for out-of-network services (73030, J3301, 99203, 20610) provided from December 3,
2019 to December 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the observation care (99226) provided on July 9, 2019 by an
out of network (OON) provider.
You asked the Plan to pay for OON observation care. You say that these services were medically necessary.
The Plan denied your request. The Plan says these services were not emergent.
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 provider at issue in this case is not a network provider with the Plan. 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 OON observation care. Our reviewer says that the criteria for coverage of this
service have not been met. Our physician reviewer found based on the medical records provided the
observation care provided on July 9, 2019 were not urgent or emergent.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of OON observation care have not been met.
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 pay for OON observation care. Therefore, we decided that the Plan
does not have to pay for the observation care (99226) provided on July 9, 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 acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 
 
We asked 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 enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee has been making gains at the sub-acute rehabilitation facility (SAR). The enrollee's care needs can be met at a lower level of 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 acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the requested IRF care is considered medically reasonable and necessary. The Plan denied your request. The Plan says the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.
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 based on review of the available records, the enrollee does not meet criteria for IRF admission. The enrollee was medically stable with no evidence of need for supervision by a physical medicine and rehabilitation physician or acute rehab nursing care. The enrollee may benefit from further physical therapy and occupational therapy but does not require an intensive therapy program. IRF admission is not medically necessary based on her current functional status and medical stability. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nursing facility care provided on January 22, 2020 and
January 27, 2020.
You asked the Plan to pay for the nursing facility care. The Plan denied your request. The Plan says nonemergent,
non-urgent services with out-of-network providers require prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we
decided that the Plan does not have to pay for nursing facility care provided on January 22, 2020 and January
27, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on October 28, 2019.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the
documentation submitted did not include a physician order/lab requisition or medical records stating exactly
what tests are to be performed.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the
medical record, his or her intent that the test be performed.
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab
requisition stating exactly which testing was to be performed. Based on this information, we decided that
Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan
does not have to pay for the drug testing services provided on October 28, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the request for admission to a skilled nursing facility
(SNF).
You asked the Plan to pre-approve the request for admission 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 the requested admission to a SNF.
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 the request for admission to a SNF. Our
reviewer says that daily skilled services are not necessary. Our physician reviewer found this enrollee does not
require skilled nursing services to safely and effectively provide medically necessary and reasonable treatment
in a SNF. There are no complex wounds, new enteral feedings, other SNF level need. The enrollee's functional
level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified
therapist to safely and effectively provide medically necessary and reasonable treatment only in a SNF. The
skilled services are not needed on a daily basis in a SNF. As a practical matter this enrollee does not require the
necessary services on an inpatient basis, in a skilled nursing facility setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the request for admission to a SNF have not been met. Therefore, we decided
that the Plan does not have to pre-approve the request for admission to a skilled nursing facility (SNF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the vision services provided on September 24, 2019 by an out of network (OON) provider.
You asked the Plan to pay for these services. You say that you thought the provider was in network. The Plan denied your request. The Plan says that they have providers in network who can provide 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 for the vision services provided on September 24, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on November 19, 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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a
physician.
We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation.
Based on this information, we decided that Medicare rules for coverage of these services have not been met.
Therefore, we decided that the Plan does not have to pay for the drug testing rendered on November 19, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Stelara.
You asked the Plan to pre-approve Stelara. You say that you would like the plan to reconsider their denial. The
Plan denied your request. The Plan says the requested drug is not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Stelara.
Benefits for Stelara 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the mandibular partial denture provided on June 7, 2019.
You asked the Plan to pay for the mandibular partial denture. You say that the initial dentures you were given
did not feel right and you were not able to use them. You also say that you went to another dentist to have new
dentures and a partial made. The Plan denied your request. The Plan says the benefit maximum had been
reached.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the Plan offers a $1,000 annual dental
benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are
responsible for the full charges of any additional dental services. The record shows that you met the annual
maximum benefit on June 7, 2019 and your annual maximum benefit was then exhausted. Therefore, we
decided that the Plan does not have to pay for the mandibular partial denture provided on June 7, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen and
pelvis and a CT scan of the chest.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are
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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee has been treated for stage
IV colon cancer, diagnosed in 2014. He has received a monitoring CT scan every three to six months. He is
now two and a half years from his last treatment, and his last CT scan was five months ago. The National
Comprehensive Cancer Network (NCCN) guidelines recommend CT monitoring every six to 12 months. As six
months have not passed from his last CT scan and there is no documentation of abnormal signs or symptoms,
the requested scans are 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 a computed tomography (CT) scan of the abdomen and pelvis and a CT scan of the chest.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from October 14, 2019 to October 29, 2019.
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you cannot afford this bill. 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $225 copayment per day for days 1-8, a $113 copayment for day 9, and a $0 copayment per day for days 10 and beyond. The enrollee has been asked to pay a $225 copayment for days 1 to 8 of the inpatient hospital stay, and a $113 copayment for day 9 of the inpatient stay, and a $0 copayment for days 10 to 15 of the inpatient stay. ($225 x 8 = $1,800). ($1,800 + $113 = $1,913).
The inpatient hospital stay falls within the "Inpatient hospital care" benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from October 14, 2019 to October 29, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge day management and subsequent hospital care provided on November 20, 2019 and November 21, 2019. 
 
You asked the Plan to pay for the hospital discharge day management and subsequent hospital care. You say that the enrollee was not in hospice on the dates of service. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on November 19, 2019. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the hospital discharge day management and subsequent hospital care provided on November 20, 2019 and November 21, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the presumptive and definitive drug testing provided on
October 23, 2019.
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the
documentation did not include a valid physician order or medical records stating exactly what tests are to be
performed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT code is not supported in the medical record. There is insufficient evidence to show that the
testing was individualized to identify specific non-prescribed medications or illicit substances. The records
provided do not document concerns based on clinical review and judgement. Based on this information, we
decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have
to pay for the presumptive and definitive drug testing provided on October 23, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for office visits provided on July 18, 2019 to August 8, 2019 by
an out of network (OON) provider.
You asked the Plan to pay for office visits. You say that you can't get prior authorization for every office visit
because you go multiple times a month. The Plan denied your request. The Plan says prior authorization is
required for these office visits with an out-of-network 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 for office visits provided on July 18, 2019 to August
8, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve toilet rails.
You asked the Plan to pre-approve the toilet rails. You say that the requested toilet rails are medically
necessary and involves patient safety in the home. The Plan denied your request. The Plan says the requested
item is not a covered benefit under Medicare or the enrollee's contract.
The Plan covers all items that Medicare covers. Medicare rules state that grab bars are not covered because
they are not primarily medical in nature.
While a grab bar may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.
Therefore, we decided that the Plan does not have to pre-approve toilet rails.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve breast augmentation surgery.
You asked the Plan to pre-approve this service. You say that breast augmentation surgery is medically necessary. The Plan denied your request. The Plan says that your request for breast augmentation surgery is considered cosmetic services and is not a covered benefit by Medicare or the health plan.
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 this service. Our reviewer says that the requested surgery is not considered medically reasonable and necessary in this case. Our physician reviewer found that based on the medical documentation and review of the photographs, your breasts appear feminine in development and appearance. Therefore, breast augmentation would be considered a cosmetic enhancement. Medicare does not pay for services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. Cosmetic surgery is excluded from coverage by Medicare. Thus, a bilateral augmentation mammaplasty does not satisfy Medicare criteria and should be considered not 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 this service have not been met. Therefore, we decided that the Plan does not have to pre-approve breast augmentation surgery.