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

We decided that the Plan does not have to pay for lab services provided to the enrollee on November 7, 2019.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the claim submitted did not include codes required to bill this service appropriately.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, the claim submitted does not include the codes required to bill for these services, as stated above. Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on November 7, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF).You asked the Plan to pre-approveadmission to a SNF. You say that the requested admission to a SNF is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee has been in an IRF since 11/24/20 after cerebral vascular accident with right hemiparesis. From a nursing perspective, theenrollee received oral and inhaled medications and insulin. The enrollee had stable vital signs. Regarding rehabilitation services, the enrollee received physical therapy, speech therapy and occupational therapy in the acute hospital. 
The enrollee was at a moderate to maximal assist level with functional mobility and working on wheelchair propulsion. The enrollee required varying assist with activities of daily living. He tolerated a regular diet.There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not meet severity of illness or intensity of service criteria for 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 admission to a SNF have not been met.Therefore, we decided that the Plan does not haveto pre-approveadmission to a skilled nursing facility (SNF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pontic - porcelain fused to high noble metal (D6240) and retainer crown - porcelain fused to high noble metal (D6750).
You asked the Plan to pre-approve pontic - porcelain fused to high noble metal (D6240) and retainer crown - porcelain fused to high noble metal (D6750). You say that the services were medically necessary. The Plan denied your request. The Plan says the services provided are not a covered benefit.
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. If a CDT code is not listed on the Plan's Schedule of Covered Services, the service is not covered. 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. Specifically, the CDT codes are not listed on the Plan's Schedule of Covered Services. Therefore, we decided that the Plan does not have to pre-approve pontic - porcelain fused to high noble metal (D6240) and retainer crown - porcelain fused to high noble metal (D6750).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadditional mileage.You asked the Plan to pre-approveadditional mileage. You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says you are covered for up to 24 one-way trips per calendar year, not to exceed 60 miles per one-way trip.Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 24 one-way transportation trips per year, not to exceed 60 miles per one-way trip. We looked at your request, the records in the case file, and the rules. The file shows that you are requesting additional mileage to your location. The Plan contract clearly states you are only covered for up to 60 miles per one-way trip.Therefore, we decided that the Plan does not have to pre-approveadditional mileage.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forout of network physician services provided to the enrollee on May 20, 2020.You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network 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 provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forout of network physician services provided to the enrollee on May 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvetwo prefabricated post and cores in addition to crowns (D2954 x2) and two gingivectomies or gingivoplasties (D4212 x2).You asked the Plan to pre-approvethe post and cores and gingivectomies or gingivoplasties. You say that these services are the most appropriate treatments for the enrollee.The Plan denied your request. The Plan says these 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 pre-approvetwo prefabricated post and cores in addition to crowns (D2954 x2) and two gingivectomies or gingivoplasties (D4212 x2).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the requested admission to an IRF is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.The Plan must followMedicare 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 thePlan was correct in denying the request to pre-approve IRF care. Our reviewer says that the enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does notrequire an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for a right below the knee amputation. Medical problems are stable. There are no identified problems that need inpatient medical management. There are no complex nursing or rehabilitation needs.The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, in an intensive rehabilitation therapy program. The medical recordsupports a need for physical and occupational therapy but it does not support a need for an intensive rehabilitation therapy program. 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-approveacute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay forphysician services provided to the enrollee. You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says the claim submitted has an inappropriate POS code.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the claim submitted cannot be paid as billed due to an issue with the reported POS code. Therefore, we decided that the Plan does not have to pay forthis service.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit provided by a participating provider July 22, 2020 on July 22, 2020.
You asked the Plan to waive the copayment for a specialist office visit. You say that you only picked up paperwork. You say that you refuse to pay this. The Plan denied your request. The Plan says the correct copayment has been applied. The Plan says that verification was made that a specialist office was schedule.
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 $40 copayment for physician/practitioner services/specialist. You have been asked to pay a $40 copayment for a specialist office visit. A specialist office visit falls within the physician/practitioner services/specialist 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 a specialist office visit provided by a participating provider July 22, 2020 on July 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on February 12, 2020 by an out of network (OON) provider.
You asked the Plan to pay for [Shorter description of ITEM or SERVICE at issue, e.g. "a power wheelchair"]. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network 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 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 medical services provided on February 12, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveOrencia (J0129) for the enrollee.You asked the Planto pre-approvethe drug. You say that this ismedically necessary.The Plandenied your request. The Plansaysthe benefit provides coverage for the requested drug when medically necessary.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the enrolle has tried and failed the required drugs. Based on the medical records provided there is no indication that the plan's required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the drug have not been met.Therefore, we decided that the Plandoes not haveto pre-approveOrencia (J0129) for the enrollee
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the debridement services provided from March 5, 2020 to May 28, 2020.
You asked the Plan to waive the copayments for the debridement services. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received outpatient surgical services on the dates of service at issue in this appeal. The Plan says that the correct copayments have applied per your contract with the Plan.
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 $325 copayment for Outpatient surgery. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received debridement services, which are considered surgical services from March 5, 2020 to May 28, 2020. You have been asked to pay a $325 copayment for the debridement services for each date of service. The debridement services fall within the Outpatient surgery 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 copayments for the debridement services provided from March 5, 2020 to May 28, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on May 8, 2020 and billed under code G0483.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says while code 80307 will be paid, code G0483 is being upheld due to insufficient information in the medical record to support the services billed. The Plan reports that five attempts to obtain the ordering provider's progress notes were documented by the resolution specialist on dates. The Plan states the denial is being upheld due to the provider not submitting progress notes that are needed in order to determine the clinical utility of the testing billed under G0483.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes and when necessary provide medical records to support the services billed. In this case, code G0483 is not supported by the records provided.
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on May 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve varicose vein ablation procedure (36465) to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the varicose vein ablation procedure. You say that you are in pain and would prefer to go to your desired cardiologist because he is closer to your home and has been your cardiologist for the past 10-15 years and you're comfortable with him. 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 varicose vein ablation procedure (36465) to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forskilled nursing facility services provided to the enrollee from April 19, 2020, to May 10, 2020 and from June 11, 2020, to June 18, 2020.You asked the Plan to pay forSNF services provided to the enrollee. You say that these services should be covered by the Plan.The Plan denied your request. The Plan says while services were covered from May 11, 2020 to June 10, 2020, all other services provided were custodial in nature. The records show the enrollee passed on June 10, 2020. The Plan must follow Medicare rules. The rules say that Medicare pays for care ina SNF when the four factors listed above are met. Custodial care is not covered.
The Plan is correct in this case. With the exception of the covered days that ledup to the enrollee's passing on June 10, 2020, the services provided were custodial in nature. Medicare coverage criteria for SNF services were not met. The records show the enrollee required maximum assist on all daily activities and was unresponsive. We have confirmed in the Medicare Beneficiary Data base that the enrollee passed on June 10, 2020. Therefore, we decided that the Plan does not have to pay forskilled nursing facility services provided to the enrollee from April 19, 2020,to May 10, 2020 and from June 11, 2020 to June 18, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve the acute inpatient hospital care.
You asked the Plan to pre-approve acute inpatient hospital care. You say that an inpatient stay is medically necessary and beneficial. The Plan denied your request. The Plan says that the enrollee can have the care needed at a lower level of care.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee presented to the emergency department with disorientation, not speaking, and right hemiparesis. It was reported that he had right hemiparesis with a recent prior CVA. In the emergency department the enrollee's speech improved and computed tomography of the head showed no evidence of acute infarct. Magnetic resonance imaging of the brain showed acute left periventricular and left basal ganglia infarct. The enrollee's vitals were stable. The records show that the admitting physician reasonably expected that the enrollee's necessary hospital care would span two midnights. The enrollee had an independent stroke which required a separate inpatient stay. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pre-approve the acute inpatient hospital care.
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveRetacrit.You asked the Plan to pre-approveRetacrit. You say that the requested drug is supported for the enrollee's condition.The Plan denied your request. The Plan says Retacrit is not supported to treat iron deficiency anemia. The Plan also says that the use of Retacrit is not medically necessary.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 Retacrit. Our reviewer says that the requested Retacrit is not medically necessary. Our physician reviewer found the documentation that was provided and compendia does not support the requested medication is being used for a medically accepted indication. Therefore, the reviewer found that the requested drug is not medical reasonable and 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 Retacrit have not been met.Therefore, we decided that the Plan does not have to pre-approveRetacrit.