Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee had open heart surgery The Plan denied your request. The Plan says the notes received do not support the need for specialized skills, they do not support the need for knowledge or judgement of a skilled professional nurse, they also do not support the need for a qualified therapist to safely provide medically necessary and reasonable treatment. The Plan states the enrollee's care can be handled at a building where skilled nursing care is done.
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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for mitral valve replacement and coronary artery bypass grafting. Medical conditions are stable.
There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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 IRF admission and services.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve multiple venous procedures intravascular ultrasound and venography with sedation (CPT code(s): 36012, 37252, 37253, 76937, 75822, 75820, 99153 and 99152), for the enrollee.

You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says that your request is not medically necessary because the enrollee's records show they do not have documented history of blood clot in either leg. The Plan states the enrollee's records do not describe problems with varicose veins of their scrotal area or any other documentation explaining by the enrollee's need these invasive venography or intravascular ultrasound procedures. The Plan states the enrollee's plan of care does not provide clear indication for the requested more extensive procedures and since the request for these procedures is not medically necessary, the requested sedation is also not 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 services. Our physician reviewer found the record indicates that the enrollee has bilateral varicose veins with greater saphenous reflux greater than 500 msec. The enrollee has increased pain when exercising, hyperpigmentation, recurrent phlebitis and swelling. The record sufficiently documents concerns for May-Thurner syndrome to establish the medical necessity and reasonableness of the requested service. The elements of the coverage rule are established. The requested services are recommended. 

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 services have been met. Therefore, we decided that the Plan has to pre-approve multiple venous procedures intravascular ultrasound and venography with sedation (CPT code(s): 36012, 37252, 37253, 76937, 75822, 75820, 99153 and 99152), for the enrollee.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient hospital service provided on January 22, 2021.

You asked the Plan to waive the copayment for the outpatient hospital service. You say that you are on a fixed income and feel the Plan should pay the whole amount. The Plan denied your request. The Plan says you were charged the copayment 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 $150 copayment for Outpatient Hospital Services.

You have been asked to pay a $150 copayment for the outpatient hospital service. The outpatient hospital service falls within the Outpatient Hospital Services 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 outpatient hospital service provided on January 22, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on September 3, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not approved in advance.

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 services at 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 for the services provided by an out-of-network provider on September 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to you by an out-pf-network provider from March 10, 2021, to March 31, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 services at 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 for the services provided to you by an out-pf-network provider from March 10, 2021, to March 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete x-rays rendered on March 2, 2021.

You asked the Plan to pay for these services. You say that the dentist assured you there would be no cost. The Plan denied your request. The Plan says the services are not covered.

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 x-rays rendered on March 2, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory work provided on July 31, 2020, by an OON
provider.
You asked the Plan to pay for the laboratory work. You say that the service was medically necessary. 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 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 laboratory work provided on July 31, 2020, by
an OON provider
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on February 22, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the primary insurer's EOB was not received.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the provider to bill the primary insurer. As the secondary insurer, the Plan cannot be held responsible for the services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the services provided on February 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit, the Part B drug, and the injection provided on
February 12, 2020 by an out-of-network (OON) provider.

You asked the Plan to pay for the office visit, the Part B drug, and the injection. You say that the services were
medically necessary. 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 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 office visit, the Part B drug, and the injection
provided on February 12, 2020 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 dental services provided by an out-of-network (OON)
provider on April 20, 2021.

You asked the Plan to pay for the dental services provided by an OON provider. You say that you would like
the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says dental services are
not covered under the Plan's supplemental benefit when provided by an OON provider.

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 dental services received by an
OON provider are not among those covered under this benefit. Therefore, we decided that the Plan does not
have to pay for the dental services provided by an out-of-network (OON) provider on April 20, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy provided on October 14, 2019.
You asked the Plan to pay for physical therapy. The Plan denied your request. The Plan says the is insufficient documentation to corroborate the services so we cannot confirm that Medicare coverage has been met.
The Plan must follow Medicare rules. Medicare rules say that when therapy services are billed as incident to a physician/NPP services, the requirement for direct supervision by the physician/NPP and other incident to requirements must be met, even though the service is provided by a licensed therapist who may perform the services unsupervised in other settings.
We looked at the file and Medicare rules. The file shows that the physical therapy was billed by a nurse practitioner. Based on this information, we decided that Medicare rules for coverage of physical therapy have not been met. Therefore, we decided that the Plan does not have to pay for physical therapy provided on October 14, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on March 26, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the office visit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.

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 the office visit provided on March 26, 2021 by an
out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the total hip replacement (CPT code 27130), for the
enrollee.

You asked the Plan to pre-approve the surgery. You say that the enrollee has undergone conservative treatment
for years and physical therapy started on April 4, 2021. The Plan denied your request. The Plan says the request
is supported when the enrollee has failed to improve following a trial of at least three (3) months of standard
treatment methods. The Plan states these treatment methods may include one, medications, physical therapy, exercises are ordered by the enrollee's prescribe and activity modification. The Plan states the enrollee's records do not show the enrollee has had a trial of treatment.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the surgery. Our physician reviewer found the enrollee was admitted in April 2021, with hip pain. Imaging did not reveal avascular necrosis or fracture. The enrollee improved with physical therapy and medical management. The record does not indicate that the enrollee continued therapy for three (3) months. The record indicates that the enrollee had a home physical therapy visit and felt the enrollee was improving. The record does not clearly document that non-conservative management has failed or is medically not appropriate. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended 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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve the total hip replacement (CPT code 27130), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the durable medical equipment provided from April 1, 2021 to April 2, 2021.
You asked the Plan to pay for the durable medical equipment. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
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 proof of delivery 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 for the durable medical equipment provided from April 1, 2021 to April 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the annual wellness visit provided on February 9, 2021, by an OON provider.

You asked the Plan to pay for the annual wellness visit. You say that the claim should be reprocessed because the Plan removed out-of-pocket costs for out-of-network COVID-19 related testing and medical treatment. 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 did not pre-approve the item/service at issue. The record shows you only had an annual wellness visit. 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 annual wellness visit provided on February 9, 2021, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the four simple extractions provided on March 24, 2021, by an OON provider.

You asked the Plan to pay for the extractions. You say that the extractions were necessary for your health. You also say that you need help paying for these services. The Plan denied your request. The Plan says these services were performed by an OON provider. The Plan also says that you are responsible for any difference between the Maximum Allowable Fee and the amount the provider bills you for the services.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, you are responsible for the difference between the billed amount and allowed amount because the services were received OON. Therefore, we decided that the Plan does not have to pay for the four simple extractions provided on March 24, 2021, by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rituxan (CPT code J9312), for the enrollee.

You asked the Plan to pre-approve the medication. You say that you requested Rituxan to treat Von Willebrand's Disease. The Plan denied your request. The Plan says the drug is not being prescribed for a medically accepted indication.

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 medication. Our physician reviewer found the record indicates that the enrollee has Von Willebrand's disease. The Food and Drug Administration has not stated that the requested drug is approved for the enrollee's condition. The Medicare approved compendia do not contain support the use of the requested drug in the enrollee's specific clinical scenario. No authoritative literature is submitted to support the use of the requested drug for the enrollee's clinical condition. The elements of the coverage rule are not satisfied. The requested service cannot be recommended. 

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 medication have not been met. Therefore, we decided that the Plan does not have to pre-approve Rituxan (CPT code J9312), for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from January 22, 2021 to February 5, 2021.

You asked the Plan to pay for home health services. You say that you feel these services should be covered. The Plan denied your request. The Plan says the services are not payable as billed.

The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. 

We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the claim was billed with an invalid number of Health Insurance Prospective Payment System (HIPPS) codes. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from January 22, 2021 to February 5, 2021.