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

We decided that the Plan does not have to pre-approve the remaining Group 3 power wheelchair accessories.
You asked the Plan to pre-approve arm rests (E0973), seat belt (E0978), joystick (E2321), power wheelchair expandable controller (E2377), power wheelchair expandable controller harness (E2313), and power wheelchair electronic connection (E2311). You say that the enrollee needs a Group 3 power wheelchair and accessories. The Plan denied your request. The Plan says the seat belt, joystick, and arm rests are included with the approved wheelchair and the approved power options come with their own switches.
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. Although there are three approved power options on the wheelchair there is not a medical need to control the power options through the joystick. The seat belt, joystick and arm rests are included in the approved power wheelchair package. Based on this information, we decided that Medicare rules for coverage of arm rests (E0973), seat belt (E0978), joystick (E2321), power wheelchair expandable controller (E2377), power wheelchair expandable controller harness (E2313), and power wheelchair electronic connection (E2311) have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair seat belt, joystick, arm rests and upgraded electronics.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on
December 12, 2020.
You asked the Plan to pay for these services. 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 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 out of network physician services provided to the enrollee on December 12, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee is not able to walk. You say that the enrollee does not have care at home because of family members who have contracted the coronavirus. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. The Plan says that the enrollee can receive the care needed in another setting.
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 coronavirus pneumonia. The enrollee's medical problems 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. While the
documentation does support a need for physical and/or occupational therapy, there is no documented need for a
intensive, multi-disciplinary rehabilitation 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-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99204, 20610, J3301) provided on February 15, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the office visit. You say that you believe that the services should be covered as an emergency. 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 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 outpatient office visit (99204, 20610, J3301) provided on February 15, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve a polysomnography (PSG) for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary to program a implanted hypoglossal nerve stimulator. The Plan denied your request. The Plan says that the records do not show any signs and symptoms of sleep apnea.
The Plan must follow Medicare rules. The rules say that hypoglossal nerve neurostimulation (HGNS) is considered medically reasonable and necessary for the treatment of moderate to severe obstructive sleep apnea when a polysomnography (PSG) is performed within 24 months of first consultation for HGNS implant. 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 reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has severe obstructive sleep apnea, and a hypoglossal nerve stimulator (HNS) was implanted on 2/23/2021. The PSG is needed to assure the HNS is properly programmed to treat the sleep disordered breathing. We looked at this physician's review, the file, and Medicare rules. Additionally, the plan has not provided any
information as to when your plan was no longer active. It appears your plan was active when the original request for services was made, however. 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 a polysomnography (PSG) 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an upgraded lens to treat presbyopia provided on January 5, 2021 and February 2, 2021.
You asked the Plan to pay for this lens upgrade. You say that you were not told these upgraded lenses would not be covered. The Plan denied your request. The Plan says the Plan contract is clear that these lenses are not covered.
The Plan covers all items that Medicare covers. Medicare does not cover an A-C IOL lens. While an A-C IOL may be appropriate for you, neither the Plan nor Medicare covers this upgrade. Therefore, we decided that the Plan does not have to pay for an upgraded lens to treat presbyopia provided on January 5, 2021 and February 2, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network outpatient mental health care provided to the enrollee on February 23, 2021.
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 Medicare guidance says payment for clinical psychologist's services via telehealth is limited to treatment by practitioners with a Psychology Doctoral degree, Licensed or certified in the State, with patient consent, and consult with the attending or primary care physician. The Plan states the records provided are insufficient to show these requirements are met. The Plan did not authorization these services.
Medicare rules say that plans can require enrollees to get prior authorization. The contract with the Plan says that outpatient mental health care may require prior authorization.
The records provided do not show the enrollee had prior authorization or a valid referral for these services. Therefore, we decided that the Plan does not have to pay for out of network outpatient mental health care provided to the enrollee on February 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral x-rays (D0220 and D0230) provided on April 5,
2021.
You asked the Plan to pay for the intraoral x-rays (D0220 and D0230). You say that the was your first visit to a
dentist since moving and x-rays were required. You say that the provider is in-network and you are appealing
the denial. The Plan denied your request. The Plan says the services are not covered benefits.
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 intraoral x-rays (D0220 and D0230) provided on April 5, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab services you received on February 19, 2021.
You asked the Plan to waive the copayment for the lab services. You say that you didn't receive pathology services, you only went to get a test for the Coronavirus. The Plan denied your request. The Plan says you were charged this 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 $5 copayment for diagnostic lab services. You have been asked to pay a $5 copayment for the lab services. Records show that you had a telehealth visit with your doctor on February 19, 2021. During that telehealth visit, your doctor ordered a not only a test for the Coronavirus, but also a respiratory panel. 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 lab services you received on February 19, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute setting.
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. The enrollee 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 she is 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. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services.
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-approve long term acute care hospital (LTACH) services for the enrollee
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 was in the hospital but then went home, fell, and went back to the hospital because she broke her hip. You also say that the enrollee wants to be back in the rehabilitation facility. The Plan denied your request. The Plan says the IRF services you are requesting do not meet the requirements for approval.
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.
Our reviewer found that the enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for a intensive, multi-disciplinary rehabilitation program. Our physician reviewer also found that 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar epidural steroid injection.
You asked the Plan to pre-approve lumbar epidural. You say that the enrollee generally has several months of relief from her epidurals. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for the epidural.
The Plan follows Medicare rules. Medicare rules state that lumbar epidural steroid injections may be covered under certain clinical conditions. 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 lumbar epidural. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested lumbar epidural steroid injection. Our physician reviewer found the enrollee is status post laminectomy with continuing pain. She had transforaminal epidural steroid injections. She had excellent results from the L5 injection but has recurring pain at L3 dermatome and the epiduralogram at the time showed intra-discal spread and it is likely that the disc protrudes through the foramen. An epidural steroid injection is not going to ameliorate a disc protrusion through the foramen. No surgical consultation has been documented. This request is not medically reasonable or 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 lumbar epidural have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar epidural steroid injection.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for wound care provided on March 24, 2021.
You asked the Plan to pay for the wound care. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 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 wound care provided on March 24, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (80299, 83789, 80307, 82542, G0480) rendered by the out-of-network (OON) provider on April 7, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without 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 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 laboratory services (80299, 83789, 80307, 82542, G0480) rendered by the out-of-network (OON) provider on April 7, 2021
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional transportation mileage. 
 
You asked the Plan to pre-approve the additional transportation mileage. You say that you need to have the 
additional transportation because of your medical condition. The Plan denied your request. The Plan says this 
service exceeds the maximum count allowed per period. 
 
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 routine transportation when each one-way trip does not exceed 50 miles of driving 
distance.

We looked at your request, the records in the case file, and the rules. Your request for an additional 24.2 miles, 
to total 74.2 miles, exceeds the benefit limit of 50 miles per one-way trip and is not covered. Based on this 
information, we decided that the Plan's rules for coverage of routine transportation have not been met. 
Therefore, we decided that the Plan does not have to pre-approve additional transportation mileage.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the blood bank physician services rendered on February 9, 2021. You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid. In this case, the MUE for CPT code 86077 is 1. You billed 2 units of this code, exceeding the MUE. 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 pay for the blood bank physician services rendered on February 9, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on January 15, 2021.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the provider did not submit laboratory results and requisition that are needed in order to determine the clinical utility of the testing.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on January 15, 2021.