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

We decided that the Plan does not have to pay for physician's services provided on August 3, 2019.
You asked the Plan to pay for the physician's services. 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 physician's services provided on August 3, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on July 24, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says non-emergent services rendered by non-participating providers in non-participating facilities require prior authorization as outlined in the enrollee's EOC.
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 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 medical services provided to the enrollee by an out-of-network provider on July 24, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy visits to be provided by the facility.
You asked the Plan to pre-approve physical therapy visits. You say that you want to go to a provider in your home town instead of traveling 30 minutes to another town and wasting money on gasoline costs. 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 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 services at issue in this appeal. The Plan did not pre-approve the physical therapy services. We found no exception that would require the Plan to pre-approve the requested physical therapy visits. Therefore, we decided that the Plan does not have to pre-approve physical therapy visits to be provided by the facility.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair power seat elevation feature.
You asked the Plan to pre-approve a power seat elevation feature. You say that the enrollee needs the power seat elevation feature. The Plan denied your request. The Plan says power seat elevation features are not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. Medicare rules say options and accessories for wheelchairs are covered if the beneficiary has a wheelchair that meets Medicare coverage criteria and the option/accessory itself is medically necessary. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair power seat elevation feature.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on September 16, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the enrollee must receive services from a participating provider.
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 provided on September 16, 2019.
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. The Plan denied your request. The Plan says the enrollee is medically stable and does not require close medical supervision.
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 current level of function is at contact guard assist with transfers and ambulation using a rolling walker, contact guard assist to supervision for bathing and toileting, and contact guard assist for bed mobility. The complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the enrollee's medical conditions requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional physical and occupational therapy, but the enrollee's current functional level does not require this on an intensive rehabilitation facility therapy program level 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a FreeStyle Libre continuous glucose monitoring system.
You asked the Plan to pre-approve a continuous glucose monitor. You say that the enrollee is reluctant to finger stick test. The Plan denied your request. The Plan says the records show the enrollee does not test at least four times a day or need frequent adjustments to the insulin regimen.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor. We looked at the file and Medicare rules. The record shows the enrollee has not started on insulin and is not testing four or more times a day. Based on this information, we decided that Medicare rules for coverage of a continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a FreeStyle Libre continuous glucose monitoring system.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
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 is with chronic obstructive pulmonary disease (COPD)and recurrent left pleural effusion and admitted to acute care on 12/25/19 after presenting with shortness of breath and persistent cough. From a nursing perspective, the enrollee received oral and inhaled medications. The enrollee had stable vital signs. She used oxygen via nasal cannula. She underwent thoracentesis and chest tube. Regarding rehabilitation services, the enrollee received physical therapy and occupational therapy in the home setting. The enrollee was at a stand by assist to contact guard assist level with transfers and she could ambulate short distances (5 feet x 2) with minimal assist. The enrollee required varying assist with activities of daily living. 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 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).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for auditory osseointegrated device, transducer/actuator, replacement only, each (L8694) provided to the enrollee on May 23, 2019.
You asked the Plan to pay for the DME. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not supported.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. Healthcare Common Procedure Coding System (HCPCS) code L8694 RA remains not supported. The documentation submitted did not include a Physician's Order to indicate the specific supplies for the billed date of service. The signed submitted order is dated October 15, 2019, the billed date of service for the item is May 23, 2019 and the delivery date of the billed item is May 28, 2019; therefore, the billed supply code cannot be supported. Of note, the physician signature can be dated after the DOS, as long as the verbal order is dated prior to or on the date of service;
however, if there is no start date or specific order date, then the signature date must be prior to the date of service. It is noted that multiple attempts were made to contact the provider for additional information. Therefore, we decided that the Plan does not have to pay for auditory osseointegrated device, transducer/actuator, replacement only, each (L8694) provided to the enrollee on May 23, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a backpack/fanny pack (E1399)
You asked the Plan to pre-approve a backpack/fanny pack. You say that you have a portable oxygen tank but cannot carry the portable oxygen in your hands due to torn left rotary cuff, right arm surgery and carpal tunnel, so you need the fanny pack pouch to carry it in. The Plan denied your request. The Plan says a backpack/fanny pack is considered a convenience item and not used to treat a medical condition.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a backpack/fanny pack (E1399).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on December 19, 2018.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the enrollee must generally receive care from an in-network provider.
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 provided on December 19, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for (A6402), (A4222), (A4649), (A4930) and (S9338) provided to the enrollee from April 1, 2019 through April 30, 2019.
You asked the Plan to pay for the DME. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not supported.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. Medicare guidance says, "Procedure code S9338 has a status code of I." You can find this information in the 2019 National Physician Fee Schedule Relative Value File April Release. Medicare guidance says Status code "I = Not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, these services." You can find this guidance in the Medicare Claims Processing Manual Chapter 23 - Fee Schedule Administration and Coding Requirements, Section 30.2.2- MPFSDB Status Indicators. Healthcare Common Procedure Coding System (HCPCS) code A4222 (3 Units) remains not supported. Healthcare Common Procedure Coding System (HCPCS) code A4930 remains not supported. Healthcare Common Procedure Coding System (HCPCS) code A6402 remains not supported. Healthcare Common Procedure Coding System (HCPCS) code A6258 remains not supported. The documentation submitted did not include a valid physician order for the billed item; therefore, the billed code cannot be verified. It is noted that multiple attempts were made to contact the provider for additional information. The documentation submitted did not include a valid physician order for the billed item; therefore, the billed code cannot be verified. It is noted that multiple attempts were made to contact the provider for additional information. Therefore, we decided that the Plan does not have to pay for (A6402), (A4222), (A4649), (A4930) and (S9338) provided to the enrollee from April 1, 2019 through April 30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the nebulizer supplies coded as A7005, A7015 and E0570 provided on August 2, 2019 to September 2, 2019 by the out of network provider.
You asked the Plan to pay for the nebulizer supplies. You say that you supplied durable medical equipment to the enrollee and the ordering provider felt it was medically necessary that the enrollee has the equipment for their medical condition and you should be paid. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. The plan says that non-emergent services with non-contracted providers require prior-authorization prior to 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 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 nebulizer supplies coded as A7005, A7015 and E0570 provided on August 2, 2019 to September 2, 2019 by the out of network provider.
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 getting enough therapy in the current setting and needs to get this care in the IRF. The Plan denied your request. The Plan says although it is noted that the enrollee can tolerate more therapy, this is available at the current facility. There is no medical issue for which the level of care at the IRF is needed as frequent physician oversight is not required.
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 requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee suffered a fall with caused a hip fracture which was treated surgically on 1/10/2020. She was admitted to a SNF for rehab but it is felt that she requires more time with therapy and for this reason, IRF care is requested. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the patient's medical status required the intensity of an IRF stay with close physician or nursing supervision. The patient may benefit and participate in additional therapy of PT and OT but the patient does not require this therapy or appear to tolerate this therapy on an intensive rehabilitation facility therapy program level 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: SNF
Decision: Favorable

We decided that the Plan has to pay for home health services provided to the enrollee from June 3, 2019 to June 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 that an incorrect Core Based Statistical Area (CBSA) number for value code 61 was used. The Plan says that chapter 10 of the Medicare Claims Processing Manual, which is for Home Health Agency Billing, speaks to the requirement of a CBSA when value code 61 is billed
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. There were 10 pages in the file submitted. Other than the denial letter there were no medical records or specific explanation of the case itself. The Plan submitted an incomplete case file from which we are unable to substantiate the Plans denial. Therefore, we decided that the Plan has to pay for home health services provided to the enrollee from June 3, 2019 to June 7, 2019.
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 pre-approve Trulicity.
You asked the Plan to pre-approve self-administered drugs. You say that you are appealing with medical records. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits. The Plan also says that the enrollee's Medicare Part D prescription drug benefits may be administered by Express Scripts.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Trulicity.
Benefits for self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the 4Kscore testing rendered on August 20, 2019.
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 testing is not covered.
The Plan must follow Medicare rules. The rules say that 4Kscore testing is not reasonable and necessary and is not covered by Medicare. The test at issue is the 4Kscore test. This test is not covered by Medicare for any indication. Therefore, we decided that the Plan does not have to pay for the 4Kscore testing rendered on August 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 16, 2019 by an out of network provider.
You asked the Plan to pay for the hospital outpatient clinic visit. You say that the services were medically necessary. The Plan denied your request. The Plan says the service provided does not meet criteria for urgent or emergent and was not authorized by 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 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 July 16, 2019 by an out of network provider.