Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids purchased at the practice on March 21, 2019.You asked the Plan to pay for the hearing aids. You say that you purchased hearing aids while shopping and never checked to see if you had coverage and you are requesting reimbursement.The Plan denied your request. The Plan says enrollee's must use a participating provider for hearing aid services.Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only The plan covers 2 hearing aids every year and has a maximum benefit of up to $500 per ear for hearing aids a year. The practice is not a participating network provider. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met.Therefore, we decided that the Plan does not have to pay for the hearing aids purchased at the practice on March 21, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient rehabilitation services (97530 and 97535) provided on July 24, 2019.You asked the Plan to pay for the outpatient rehabilitation services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says prior authorization is required for outpatient therapy visits.Medicare rules say that plans can require enrollees to obtain authorization before receiving services. The contract with the Plan says that outpatient rehabilitation services require prior authorization.The Plan did not pre-approve the item/service at issue. The record indicates the Plan made multiple attempts to inform the provider of the prior authorization rules. 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 outpatient rehabilitation services (97530 and 97535) provided on July 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician's services provided on October 16, 2018.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-urgent, non-emergent services require prior authorization. The Plan requires utilization of network providers when possible and available.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 the physician's services provided on October 16, 2018.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by the practice on May 14, 2019 to May 15, 2019.You asked the Plan to waive the copayment foran inpatient hospital stay. You say that you should only have to pay for the emergency room visit.The Plan denied your request. The Plan says the correct copayment has been applied.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 $360 copayment per day for days 1-5. There is a $0 copayment for additional days for inpatient hospital care. You have been asked to pay a $360 copayment per day for days 1-5. There is a $0 copayment for additional days for an inpatient hospital stay. When you admitted to the hospital from the emergency room, the emergency room copayment is waived; therefore, you are being asked to pay $360 for your inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment fo ran inpatient hospital stay provided by the practice on May 14, 2019 to May 15, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for a behavioral health office visit provided by the physician on July 15, 2019.You asked the Plan to pay for the behavioral health office visit. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.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 behavioral health office visit provided by the physician on July 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided the physician on June 26, 2019.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-urgent, non-emergent services require prior authorization. The Plan requires utilization of network providers when possible and available.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 by the physician on June 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nurse practitioner services for a domiciliary or rest home visit provided on July 23, 2019.You asked the Plan to pay for the nurse practitioner services. The Plan denied your request. The Plan says non-urgent, non-emergent services require prior authorization. The Plan requires utilization of network providers when possible and available.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 service sat issue. We found no exception that would require the Plan to pay for theseservices. Therefore, we decided that the Plan does not have to pay for nurse practitioner services for a domiciliary or rest home visit provided on July 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services for debridement of nails provided on February 26, 2019.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-urgent, non-emergent services require prior authorization. The Plan requires utilization of network providers when possible and available.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 physician's services for debridement of nails provided on February 26, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient rehabilitation services provided on July 29, 2019.You asked the Plan to pay for the outpatient rehabilitation services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says outpatient rehabilitation services require prior authorization.Medicare rules say that plans may require enrollees to obtain authorization before receiving services. The contract with the Plan says outpatient rehabilitation services require prior authorization.The Plan did not pre-approve the item/service at issue. Records indicate the Plan made multiple attempts to inform the provider of the prior authorization requirement. 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 outpatient rehabilitation services provided on July 29, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a convergent procedure (33266). You asked the Plan to pre-approve a convergent procedure. You say that because medications have not worked, this surgery is medically necessary. The Plan denied your request. The Plan says this surgery is experimental and investigational. The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a convergent procedure. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found the convergent procedure is a hybrid surgical option for patients with atrial fibrillation that can be considered when medical therapy and percutaneous ablative options have proven ineffective. If ablation were thought to be medically necessary, current guidelines do not recommend a hybrid surgical approach to ablation over conventional percutaneous ablation.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a convergent procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a convergent procedure (33266).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services (97110, 97530, and 97116) provided from June 18, 2019 to June 20, 2019.You asked the Plan to pay for physical therapy services. You say that these services were medically necessary.The Plan denied your request. The Plan says these services were not authorized.The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.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 physical therapy services. Our reviewer says that skilled services were not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the records do not demonstrate that the unique skills of a professional therapist were required to safely and effectively provide treatment, or that the services could be safely and effectively performed only by a therapist during the dates at issue. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of physical therapy services have not been met.Therefore, we decided that the Plan does not have to pay for physical therapy services (97110, 97530, and 97116) provided from June 18, 2019 to June 20, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services, provided on July 11, 2019, by out of network provider.You asked the Plan to pay for the ambulance services. You say that this service was medically necessary.The Plan denied your request. The Plan says this service was 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 has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the service 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 ambulance services,provided on July 11, 2019, by out of network provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 6 additional physical therapy visits.You asked the Plan to pre-approve 6 additional physical therapy visits. You say that extenuating circumstances have slowed your therapy progress.The Plan denied your request. The Plan says you have not made as much progress as you should, so only 6 visits are necessary. The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.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 6 additional physical therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found there is no indication prior physical therapy has served to provide sustained, significant improvement in pain and/or function and there is no indication residual deficits could not be addressed via a home exercise program.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 6 additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 6 additional physical therapy visits.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee. You asked the Plan to pre-approve admission to a skilled nursing facility (SNF). You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet criteria. 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 skilled nursing facility (SNF). Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the hospital with a urinary tract infection with sepsis. From a nursing perspective, the enrollee received oral medications and IV antibiotics. The enrollee had stable vital signs. He was to complete a course of IV antibiotics in the home setting. He was treated for chronic ankle pain. He had routine chronic foley catheter care. Regarding rehabilitation services, the enrollee received physical therapy and occupational therapy in the acute hospital. The enrollee was at a stand by assist level with functional mobility including gait to 100 feet x 2with a rolling walker. The enrollee required varying assist with activities of daily living. There are 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 skilled nursing facility (SNF) have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the Outpatient Occupational and Physical Therapy (OT/PT) services provided from May 17, 2019 to June 26, 2019.You asked the Plan to pay for the Outpatient PT/OT services. You say that the PT and OT services provided from May 17, 2019 to June 26, 2019 were medically necessary.The Plan denied your request. The Plan says the PT and OT services provided from May 17, 2019 to June 26, 2019 were not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.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 the Outpatient PT/OT services. Our reviewer says that skilled services were not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the enrollee is status post cerebral vascular accident October 2018 with residual right upper extremity weakness. The enrollee initially received PT and OT at an inpatient rehabilitation facility and has continued PT and OT services at the Assisted Living Facility since that time. Her level of function as of 5-9-19 PT notes and 5-15-19 OT notes was ambulating 240 feet with a rolling walker with minimal assist, transfers with minimal/standby assist, upper body dressing independently, lower body dressing with minimal assist, bathing with minimal assist, and performing therapeutic exercises. The notes indicate the enrollee had plateaued with her level of function with PT and OT. Based on available records, the enrollee does not meet criteria for coverage of the PT and OT services provided from May 17, 2019 to June 26, 2019. The records do not demonstrate that the unique skills of a professional therapist were required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist during the dates at issue.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 Outpatient PT/OT services have not been met.Therefore, we decided that the Plan does not have to pay for the Outpatient Occupational and Physical Therapy (OT/PT) services provided from May 17, 2019 to June 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a hospital outpatient clinic visit provided on July 29, 2019.You asked the Plan to pay for the hospital outpatient clinic visit. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.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 hospital outpatient clinic visit provided on July 29, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient rehabilitation services (97530, 97535 and 97112) provided on July 31, 2019.You asked the Plan to pay for the outpatient rehabilitation services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says prior authorization is required for outpatient therapy services.Medicare rules say that plans may require enrollees to obtain authorization before receiving services. The contract with the Plan says that prior authorization is required for outpatient rehabilitation services.The Plan did not pre-approve the item/service at issue. The record indicates that the Plan made multiple attempts to inform the provider of the prior authorization requirement. 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 outpatient rehabilitation services (97530, 97535 and 97112) provided on July 31, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for occupational therapy services provided on August 9, 2019.You asked the Plan to pay for occupational therapy services. You say that these services were medically necessary.The Plan denied your request. The Plan says these services were not authorized.The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.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 occupational therapy services. Our reviewer says that skilled services were not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found in this case, there is no indication prior physical therapy has served to provide sustained, significant improvement in pain and/or function and there is no indication residual deficits could not be addressed via a home exercise program.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of occupational therapy services have not been met.Therefore, we decided that the Plan does not have to pay for occupational therapy services provided on August 9, 2019.