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

We decided that the Plan does not have to pay for the physician services provided on October 23, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the physician services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide 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 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 physician services provided on October 23, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Life Alert device.
You asked the Plan to pre-approve the requested item. You say that the device will provide comfort in knowing you are safe. The Plan denied your request. The Plan says the item is not a covered benefit.
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 Life Alert device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 24 tracheostomy cleaning brushes.
You asked the Plan to pre-approve 24 tracheostomy cleaning brushes (A4626). You say that you need these supplies. The Plan denied your request. The Plan says the amount of supplies requested is more than what is reasonable and necessary.
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. The physician order for cleaning brushes is 2 per month and there is no explanation in the medical record why there is a need for more than the maximum. Based on this information, we decided that Medicare rules for coverage of 24 tracheostomy cleaning brushes (A4626) have not been met. Therefore, we decided that the Plan does not have to pre-approve 24 tracheostomy cleaning brushes.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility visit provided by an out-of-network
provider on October 5, 2020.
You asked the Plan to pay for the nursing facility visit. You say that the physician depends on the hospital staff
to verify eligibility and obtain proper authorization. You say that medically necessary services were provided,
and the doctor is seeking reimbursement. The Plan denied your request. The Plan says authorization for out of
network services was not obtained.
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
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 nursing facility visit provided by an out-of-network
provider on October 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit provided by an out-of-network provider on January 26, 2021.
You asked the Plan to pay for the home visit. You say that the service was denied for no authorization, but the treatment was medically necessary. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not approved in advance.
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 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 home visit provided by an out-of-network provider on January 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone grafting in preparation for dental implants.
You asked the Plan to pre-approve bone grafting in preparation for dental implants. You say that you would
like the Plan to reconsider their denial. The Plan denied your request. The Plan says the Plan's supplemental
dental benefit does not cover implants or any related services to implants.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve bone
grafting in preparation for dental implants.
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 you would like the IRF services to be authorized for the enrollee. The Plan denied your request. The Plan says the IRF services are not medically necessary.
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. The enrollee does require physical and occupational therapy, but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care.
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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide additional routine health-related transportation trips.
You asked the Plan to provide additional transportation trips. You say that you cannot drive so you need additional trips for upcoming appointments. The Plan denied your request. The Plan says additional transportation cannot be added after you have utilized the maximum number of transportation trips allowed per year.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 40 trips per year.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to provide additional routine health-related transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the cervical collar provided by an out-of-network provider on February 17, 2021.
You asked the Plan to pay for the cervical collar. You say that you are not part of the hospital and was unable to obtain pre-authorization at the time of service. You say that the product was dispensed by the hospital physician to the patient with the expectation to be reimbursed. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not approved in advance.
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 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 cervical collar provided by an out-of-network provider on February 17, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation (A0429) received November 15, 2020.
You asked the Plan to waive the copayment for the ambulance transportation. You say that it is not your fault that the hospital lost power and you needed to be transferred to another facility. The Plan denied your request. The Plan says the correct cost share applied to the claim.
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 $225 copayment for each Medicare-covered one-way trip by ground transportation. You have been asked to pay a $225 copayment for the ambulance transportation. You received a one-way ambulance trip by ground transportation. 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 ambulance transportation (A0429) received November 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for a weight loss program from February 22, 2020, through February 10, 2021.
You asked the Plan to reimburse you for the weight loss program. The Plan denied your request. The Plan says the weight loss program is not a covered benefit.
The Plan contract offers health and wellness education programs.
We looked at the file and the Plan's rules. The file shows that a weight loss program is not a covered benefit. Therefore, we decided that the Plan does not have to reimburse you for a weight loss program from February 22, 2020, through February 10, 2021.
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 you have the stamina and desire to do the intense rehab. The Plan denied your request. The Plan says you are without any notable skilled nursing needs that would require the management by a physiatrist.
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 physician reviewer found that you were admitted to the acute care hospital for a below knee amputation. Your medical conditions are stable. There are no complex nursing needs. You do not require treatment by multiple therapies in an intensive rehabilitation therapy program. You do require physical and occupational therapy, but there is no documented need for an intensive rehabilitation 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.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient mental health care from June 16,
2021, forward.
You asked the Plan to pre-approve continued inpatient mental health care from June 16, 2021, forward. You
say that continued inpatient mental health care from 6/16/21 and forward is medically necessary. The Plan
denied your request. The Plan says continued inpatient mental health care from 6/16/21 and forward is not
medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the
patient requires active treatment.
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 continued inpatient mental health care
from June 16, 2021, forward. Our reviewer says that continued inpatient mental health care from 6/16/21 and
forward is not medically necessary. Our physician reviewer found this enrollee does not require inpatient
mental health treatment beyond the dates in question as he is not a danger to himself or others and does not
have any delusions, auditory or visual hallucinations. It does not appear that active treatment is taking place
beyond the date in question. It does not appear that the services for the dates in question are reasonably
expected or medically necessary to improve the enrollee's condition or for the purpose of diagnosis. I am
unable to find an individualized treatment plan however the entire record is not present. It appears that the
services were supervised and evaluated by a physician. Based upon review of the records provided, this
enrollee does not meet the criteria for treatment in an acute inpatient mental health setting beyond the date in
question of June 16, 2021 and forward. The enrollee can be treated in a lesser restrictive setting as he is not
showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions and was not showing
any behaviors while being cooperative and compliant and not showing any acute threats to safety.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of continued inpatient mental health care from June 16, 2021, forward have not
been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient mental health
care from June 16, 2021, forward.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on September 24, 2020, by
an OON provider.
You asked the Plan to pay for the physician services provided by an OON provider. You say that you would
like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services
provided were neither emergent nor urgent and prior authorization was not obtained to provide 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 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 physician services provided on September 24,
2020, by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the IRF services provided from September 15, 2020, through September 29, 2020.
You asked the Plan to pay for the IRF services. The Plan denied your request. The Plan says the health Plan requires utilization of network providers when possible and available, and requires authorization for certain 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 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 IRF services provided from September 15, 2020, through September 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an apicoectomy - anterior (D3410), removal of benign odontogenic cyst or tumor - lesion diameter up to 1.25 cm (D7450), retrograde filling - per root (D3430), and incisional biopsy of oral tissue-soft (D7286).
You asked the Plan to pre-approve an apicoectomy, removal of benign odontogenic cyst or tumor, retrograde filling, and incisional biopsy of oral tissue. You say that these services are medically necessary for your overall health. The Plan denied your request. The Plan says these services are not covered under your 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 pre-approve an apicoectomy - anterior (D3410), removal of benign odontogenic cyst or tumor - lesion diameter up to 1.25 cm (D7450), retrograde filling - per root (D3430), and incisional biopsy of oral tissue-soft (D7286).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the insertion of a tunneled centrally inserted central venous access device (36561) provided on February 1, 2021.
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to the service provided.
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 20% coinsurance for each surgical or observation room service you get at an outpatient hospital.
You have been asked to pay $552.07 ($2760.36 x 20% coinsurance) for the outpatient surgery provided. 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 coinsurance for the insertion of a tunneled centrally inserted central venous access device (36561) provided on February 1, 2021.
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 meets the full criteria for coverage. The
Plan denied your request. The Plan says this is not medically necessary.
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 patient does not require treatment by multiple therapies and an intensive
rehabilitation therapy program. While the patient does require physical and occupational therapy, there is no
documented need for an intensive rehabilitation program. Medically necessary services can be provided in a
different level of care. There is not a reasonable expectation that this patient 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.