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

We decided that the Plan does not have to pay for the wrist hand finger orthosis provided on August 23, 2019 by an out of network provider.
You asked the Plan to pay for the wrist hand finger orthosis (L3809). You say that the orthosis was medically necessary. The Plan denied your request. The Plan says you did not have prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the item at issue in this appeal. The Plan did not pre-approve the item at issue. We found no exception that would require the Plan to pay for this item. Therefore, we decided that the Plan does not have to pay for the wrist hand finger orthosis provided on August 23, 2019 by an out of network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services provided on September 30, 2019.
You asked the Plan to pay for the ambulance services. You say that the ambulance services were a health emergency. The Plan denied your request. The Plan says the provider must file the claim with your primary insurer first.
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 send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible for the ambulance services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for ambulance services provided on September 30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the ankle foot orthoses provided on May 1, 2019.
You asked the Plan to pay for the ankle foot orthoses (L1971). You say that the orthoses was medically necessary. The Plan denied your request. The Plan says medical necessity is not supported in the medical records.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file, and Medicare rules. There is no mention in the office notes of the orthoses. Based on this information, we decided that Medicare rules for coverage of the ankle foot orthoses (L1971) have not been met. Therefore, we decided that the Plan does not have to pay for the ankle foot orthoses provided on May 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye exam provided on November 25, 2019.
You asked the Plan to waive the copayment for the eye exam. You say that you do not want to pay the $25. You state that you were the one that said you might have a cataract in years to come and the provider never mentioned that to you. You state this was supposed to be free. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received the exam because of a blur at a distance in both eyes. You also were diagnosed with a nuclear cataract in left eye. Therefore, you are asked to pay a $25 copayment for the diagnostic exam. 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 eye exam provided on November 25, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for services provided on September 27, 2019.
You asked the Plan to pay for the ambulance services. You say that the ambulance services were a health emergency. The Plan denied your request. The Plan says the provider must file the claim with your primary insurer first.
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 send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible for the ambulance services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for services provided on September 27, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from July 25, 2019 to July 31, 2019.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee did not require any additional skilled services that could not have been provided in an alternate setting other than a SNF.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. 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 the skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from July 25, 2019 to July 31, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the remaining 16 physical therapy (PT) visits.
You asked the Plan to pre-approve the remaining 16 physical therapy (PT) visits. You say that the remaining 16 PT visits are medically necessary. The Plan denied your request. The Plan says the remaining 16 PT visits are 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 pre-approve the remaining 16 physical therapy (PT) 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 the requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition. The enrollee is noted to be making slow progress and with persistent deficits without recent physician follow up. The records do not demonstrate that the enrollee requires the unique skills of a professional therapist to safely and effectively provide treatment, that services can be safely and effectively performed only by a therapist, or under supervision of a therapist. The enrollee is versed in an independent home exercise program (HEP). The enrollee has not had recent physician follow up therefore it is not clear that he requires ongoing skilled PT for his condition. The services are not part of a maintenance program. The specialized skill, knowledge and judgment of a qualified therapist are not required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. 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 remaining 16 physical therapy (PT) visits have not been met. Therefore, we decided that the Plan does not have to pre-approve the remaining 16 physical therapy (PT) visits.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that the enrollee still requires SNF services. The Plan denied your request. The Plan says the enrollee has exceeded limits set in the subscriber agreement.
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. The file shows that you received 100 days of SNF care during the benefit period from August 10, 2019 through August 26, 2019, September 5, 2019 through November 8, 2019 and February 10, 2020 through March 1, 2020. The Plan has covered 100 days of SNF care. Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. You will be eligible for a new benefit period when you have not been receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on October 24, 2019 by an out of network (OON) provider.
You asked the Plan to pay for physician services. You say that these services were medically necessary. The Plan denied your request. The Plan says the referring facility is out-of-network. The Plan says that no prior authorization was obtained for these services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for physician services provided on October 24, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the catheter placement services provided during a procedure on September 4, 2019 billed with CPT code 93460.
You asked the Plan to pay for the billed services. You say that this code is supported. The Plan denied your request. The Plan says that the operative note does not include adequate documentation of left heart catheterization.
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 CPT Code Manual definition of code 93460 is Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right and left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed. 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 billed services. Our reviewer says that the medical records support the billing of this code. Our physician reviewer found The enrollee is a 79-year-old woman with diagnoses of ST elevation (STEMI) myocardial infarction involving other sites, Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris, Ischemic cardiomyopathy, and Acute on chronic systolic (congestive) heart failure. The Invasive Cardiology Note dated 9/4/19 documents a left heart catheterization with evaluation of the right coronary artery, left main artery, LAD, and LCX, as well as a right heart catheterization with evaluation of pulmonary artery pressures. 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 billed services have been met. Therefore, we decided that the Plan has to pay for the catheter placement services provided during a procedure on September 4, 2019 billed with CPT code 93460.
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 pay foroutpatient hospital services provided on September 17, 2019 by an out of network (OON) provider.You asked the Plan to pay foroutpatient hospital services. You say that these services were medically necessary for the enrollee.The Plan denied your request. The Plan says no prior authorization was obtained for these services. The Plan says that the referring hospital is also 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 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 foroutpatient hospital services provided on September 17, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forEKG monitoring provided on September 6, 2019 to September 27, 2019 by an out of network (OON) provider.You asked the Plan to pay forEKG monitoring. You say that these services were medically necessary. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says no prior authorization was obtained for these services. The Plan says that there are in-network providers available for the same services.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forEKG monitoring provided on September 6, 2019 to September 27, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve stereotactic radiosurgery (SRS) and stereotactic body radiation therapy (SBRT)
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that SRS and SBRT are covered when specific criteria are met. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has stage III non-small cell lung cancer (NSCLC) and an escalating dose of radiation with concurrent chemotherapy did not improve outcomes. SBRT is only indicated as primary treatment for tumor types or locations where the available published literature supports an outcome advantage over other conventional radiation modalities. SRS is not medically necessary, as only one lung lesion is being targeted. SBRT is meant to represent a complete course of treatment and not to be used as a boost following a conventionally fractionated course of treatment. Given that SBRT is being requested as a boost, the services are not reasonable or medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve stereotactic radiosurgery (SRS) and stereotactic body radiation therapy (SBRT)
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 needs continued close medical supervision, and specialized nursing care to ensure safety. The Plan denied your request. The Plan says the enrollee's medical condition appears stable, and there are no medical issues that require physician supervision three times a week.

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 physician reviewer found that the enrollee's medical conditions appear stable. There is no complex wound care needs. There are no unaddressed medical issues. He does not require medical oversight of his condition at an acute hospital level of care. The enrollee requires physical therapy for mobility and occupational therapy for remaining activities of daily living and adaptive equipment. However, he has a new unilateral right lower extremity impairment without identified significant upper extremity impairment and does not require the intensity of an acute level rehabilitation therapy program. The enrollee is limited by pain after his recent fall and surgery. He would not be expected to be able to fully participate in or benefit from the required intensity of an acute rehabilitation therapy 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.