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

We decided that the Plandoes not haveto pay forthe COVID-19 testing provided on June 11, 2020.You asked the Planto pay forthe COVID-19 testing. You say that you were required by the state to have this testing done regularly as a condition of your employment. You were told that this had to be covered by all insurance companies.The Plandenied your request. The Plansaysthis type of testing which is done solely due to third party requirements is not covered by Medicare.The Plan must follow Medicare rules. Medicare rules say that testing required for employment or by other third parties is not eligible for coverage.Although this testing was appropriate and required, the rules do not allow Medicare to make payment for testing in this situation.Therefore, we decided that the Plandoes not haveto pay forthe COVID-19 testing provided on June 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a nebulizer provided on July 10, 2020.
You asked the Plan to pay for the nebulizer. The Plan denied your request. The Plan says you must receive
your care from a network provider. In most cases, care you receive from an out -of-network provider will not be
covered. If you need medical care that Medicare requires our plan to cover and the providers in our network
cannot provide this care, you can get this care from an out-of-network provider. You, or your PCP, must obtain
authorization from the plan prior to seeking care.
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
nebulizer. We found no exception that would require the Plan to pay for these items. Therefore, we decided that
the Plan does not have to pay for a nebulizer provided on July 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Tandem T-Slim external ambulatory insulin infusion pump.
You asked the Plan to pre-approve Tandem T-Slim pump. You say that the enrollee's blood glucose levels have been widely variable with use of the current insulin pump, and using the Tandem T-Slim pump in tandem with a continuous glucose monitor will very likely result in overall improved control and quality of life. The Plan denied your request. The Plan says the denial of authorization for this device is correct, because the records do not show that the enrollee's current pump is malfunctioning, and it is still under warranty.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and 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 Tandem T-Slim. Our reviewer says that the enrollee does not meet the criteria for the requested infusion pump. Our physician reviewer found that there is no documentation provided indicating that the enrollee's current infusion pump has malfunctioned, and the current equipment is under warranty until August 18, 2021.
The file shows that the enrollee currently has an infusion pump. The current infusion pump serves the same purpose as Tandem T-Slim pump. Therefore, we decided that the Plan does not have to pre-approve a Tandem T-Slim external ambulatory insulin infusion pump.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient diagnostic services provided on August 29, 2019.
You asked the Plan to pay for the outpatient diagnostic services. The Plan denied your request. The Plan says
the Plan requires utilization of network providers when possible and available, and requires authorization for
certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency
situation, has been documented.
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 outpatient diagnostic services provided on August 29, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe skilled nursing facility (SNF) services provided from August 12, 2020, to August 27, 2020.You asked the Plan to pay forSNF services provided from August 12, 2020, to August 27, 2020. You say that the services which the enrollee required and received during the dates of service are coverable under the Medicare Act.The Plan denied your request. The Plan says the criteria for continued SNF level of coverage were not met. The Plan also says that there were no daily skilled services provided.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 pay for SNF services provided from August 12, 2020,to August 27, 2020. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, 
knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 SNF services provided from August 12, 2020,to August 27, 2020 have not been met.Therefore, we decided that the Plan does not have topay forthe skilled nursing facility (SNF) services provided from August 12, 2020, to August 27, 2020
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe initial hospital care, per day (99222) provided on August 25, 2019.You asked the Plan to pay forthis service. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says the service is not payable as the claim was submitted untimely.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 this service was not filed until September 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 forthe initial hospital care, per day (99222) provided on August 25, 2019
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a mammography provided on October 7, 2020
You asked the Plan to pay for the mammography. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or
emergent, nor were they 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 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 a mammography provided on October 7, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on May 20, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says prior
authorization was not obtained by the provider or facility.
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 May 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for intermittent limb compression device.
You asked the Plan to pay for intermittent limb compression device. You say that the enrollee requires the
device. The Plan denied your request. The Plan says the documentation failed to prove that sufficient evidence
of four-week trial of conservative therapy.
The Plan follows Medicare rules. The rules state that a PCD coded as E0651 is covered for the treatment of
lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers. A four-week
trial of conservative therapy demonstrating failed response to treatment is required.
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least
four weeks of regular home usage of conservative therapy including compression garments, exercise and
elevation. Therefore, we decided that the Plan does not have to pay for intermittent limb compression device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe pneumatic device provided on August 6, 2020.You asked the Plan to pay forthe pneumatic device. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says pneumatic compression devices are not covered by Medicare for the enrollee's condition.The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers.The file doesnot show that the enrollee has lymphedema and/ or chronic venous insufficiency with venous stasis ulcers.Therefore, we decided that the Plan does not have to pay forthe pneumatic device provided on August 6, 2020.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to waive the copayment for the colonoscopy provided on August 19, 2020.
You asked the Plan to waive the copayment for the colonoscopy. You say that no polyps were found and you
do not understand why you are being charged a copayment. The Plan denied your request. The Plan says that
polyps were removed and 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 says that enrollees must pay a
$0 copayment for a Medicare-covered colorectal cancer screening exam.
The Plan says the enrollee must pay a $200 copayment for the colonoscopy. Based on the plan contract,
however, the enrollee cannot be asked to pay more than a $0 copayment for the colonoscopy. The medical
record shows that no polyps were removed. Therefore, we decided that the Plan has to waive the copayment for
the colonoscopy provided by on August 19, 2020.
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF care. You say that the stay is medically necessary.The Plan denied your request. The Plan says the stay 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 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 requestedIRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for surgical repair of a hip fracture after a fall. Medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. Youdo not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that you 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-approveacute IRF admission and services.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve arthrodesis (22551, 22552), an allograft (20930), anterior
segmentation (22846), and the insertion of a biomechanical device (22853).
You asked the Plan to pre-approve arthrodesis, an allograft, anterior segmentation, and the insertion of a
biomechanical device. You say that the enrollee needs these services. The Plan denied your request. The Plan
says that this is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item
or service, then that item or service will be covered when it is medically necessary.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve arthrodesis, an allograft, anterior
segmentation, and the insertion of a biomechanical device. Our reviewer says that the requested services are
considered medically reasonable and necessary in this case. Our physician reviewer found the criteria for
multilevel cervical fusion surgery is met. The patient has spinal cord compression at multiple levels. The
patient is also myelopathic with difficulty picking up objects and walking. Decompression and fusion surgery
at multiple levels is warranted in this case.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of arthrodesis, an allograft, anterior segmentation, and the insertion of a
biomechanical device have been met. Therefore, we decided that the Plan has to pre-approve arthrodesis
(22551, 22552), an allograft (20930), anterior segmentation (22846), and the insertion of a biomechanical
device (22853).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the preventive procedure (D1999), two prefabricated
abutments (D6056 x2), and abutment supported porcelain/ceramic crown (D6058) on tooth #13 provided on
August 27, 2020 by an OON provider.
You asked the Plan to pay for the preventive procedure, prefabricated abutments, and abutment supported
crown. You say that you purchased the extra comprehensive dental benefit to cover the crowns that you needed
to have done. You also say that you were told you could go OON, and the claims would be paid but not as
much. The Plan denied your request. The Plan says the preventive procedure and prefabricated abutment are
not covered benefits. The Plan also says that you were billed correctly for the abutment supported crown, and
your abutment supported crown benefit has been exhausted.
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 unspecified preventive procedure
(D1999) and prefabricated abutment (D6056) are not among those covered under this benefit. The Plan also
says that you are responsible for a 50% coinsurance for the abutment supported porcelain/ceramic crown
(D6058), and you are also responsible for the difference between the billed amount and allowed amount.
Therefore, we decided that the Plan does not have to pay for the preventive procedure (D1999), two
prefabricated abutments (D6056 x2), and abutment supported porcelain/ceramic crown (D6058) on tooth #13
provided on August 27, 2020 by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveLTACH services.You asked the Plan to pre-approvethe LTACH services. You say that the stay is medically necessary.The Plandenied your request. The Plan says the stay is not medically necessary.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. Our physician reviewer found there is no documentation provided necessitating admission to a LTACH.  The enrollee still requires acute hospital level of care services and is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where they are currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approveLTACH services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray provided on September 16, 2020 by an out of
network (OON) provider.
You asked the Plan to pay for the OON x-ray. You say that the records provided support the services in
dispute. The Plan denied your request. The Plan says the OON services were not urgent, emergent, or 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 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 x-ray provided on September 16, 2020 by an
out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea genicular nerve block for the enrollee.You asked the Planto pre-approvethe block. You say that this is medically necessary.The Plandenied your request. The Plansaysmedical studies have not proven that this procedure is helpful for treatment of the health problem.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 block. Our reviewer says that the requested block is not considered medically reasonable and necessary in this case. Our physician reviewer found genicular nerve blocks and genicular nerve ablationare considered investigational and not medically necessary for the treatment of chronic knee pain, including, but not limited to any of the following:  degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee replacement; as a treatment following knee replacement; or as a treatment for individuals who are not candidates for knee replacement surgery.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 block have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea genicular nerve block for the enrollee.